Yonsei Med J.  2018 Jun;59(4):524-538. 10.3349/ymj.2018.59.4.524.

Minimally Invasive Lumbar Spinal Fusion Is More Effective Than Open Fusion: A Meta-Analysis

• Park Y
• Seok SO
• Lee SB
• Ha JW

• KMID: 2410908
• DOI: http://doi.org/10.3349/ymj.2018.59.4.524

Abstract

PURPOSE
To evaluate the efficacy of minimally invasive spinal fusion in comparison to open fusion for adult lumbar spondylolisthesis or spondylosis.
MATERIALS AND METHODS
The present study was conducted as a meta-analysis of all estimates from studies that were selected after comprehensive literature search by two independent reviewers.
RESULTS
Of 745 articles, nine prospective cohort studies were identifed. The quality of evidence was downgraded because of study design, inconsistency, imprecision, and publication bias. Greater Oswestry Disability Index score improvement [weighted mean difference (WMD), 3.2; 95% confdence interval (CI), 1.5 to 5.0; p=0.0003] and a lower infection rate (odds ratio, 0.3; 95% CI, 0.1 to 0.9; p=0.02) were observed in the minimally invasive group (low-quality evidence). The minimally invasive group had less blood loss (WMD, 269.5 mL; 95% CI, 246.2 to 292.9 mL; p < 0.0001), a shorter hospital stay (WMD, 1.3 days; 95% CI, 1.1 to 1.5 days, p < 0.0001), and longer operation time (WMD, 21.0 minutes; 95% CI, 15.9 to 26.2 minutes; p < 0.0001) and radiation exposure time(WMD, 25.4 seconds; 95% CI, 22.0 to 28.8 seconds, p < 0.0001) than the open group (low-quality evidence). There were no significant differences in pain improvement, fusion rate, complications, or subsequent surgeries between the two treatment groups (lowquality evidence).
CONCLUSION
Although present findings are limited by insufficient evidence and there is a lack of adequately powered high-quality randomized controlled trials to address this gap in evidence, our results support that minimally invasive lumbar fusion is more effective than open fusion for adult spondylolisthesis and other spondylosis in terms of functional improvement, reducing infection rate, and decreasing blood loss and hospital stay.

Keyword

Minimally invasive; percutaneous pedicle screw; spinal fusion; lumbar spine; efficacy; meta-analysis

MeSH Terms

Adult
Cohort Studies
Humans
Length of Stay
Prospective Studies
Publication Bias
Radiation Exposure
Spinal Fusion*
Spondylolisthesis
Spondylosis

Figure

• 

  Fig. 1 Flow diagram demonstrating the individual steps in the literature-selection process.

• 

  Fig. 2 Comparisons of ODI scores for functional improvement and VAS scores for back pain and leg pain between minimally invasive and open lumbar spinal fusion. Heterogeneity: ODI score [τ2=0.000; χ2=2.549, df=4 (p=0.636); I2=0.0%], VAS back pain [τ2=0.000; χ2=1.192, df=4 (p=0.879); I2=0.0%], and VAS leg pain [τ2=0.000; χ2=0.748, df=1 (p=0.387); I2=0.0%]. ODI, Oswestry Disability Index; VAS, visual analogue scale; df, degrees of freedom; CI, confidence interval.

• 

  Fig. 3 Comparison of fusion rates between minimally invasive and open lumbar spinal fusion. Heterogeneity: fusion rates for PLF [τ2=0.000; χ2=0.000, df=0 (p=1.000); I2=0.0%], fusion rates for PLIF [τ2=0.000; χ2=0.701, df=1 (p=0.402); I2=0.0%], fusion rates for TLIF [τ2=0.000; χ2=1.836, df=4 (p=0.766); I2=0.0%], and overall fusion rates [τ2=0.000; χ2=3.925, df=7 (p=0.788); I2=0.0%]. PLF, posterolateral fusion; PLIF, posterior lumbar interbody fusion; TLIF, transforaminal lumbar interbody fusion; df, degrees of freedom; OR, odds ratio; CI, confidence interval.

• 

  Fig. 4 Comparison of complications rates (hardware-related, neurological, and surgical-site complications) between minimally invasive and open lumbar spinal fusion. Heterogeneity: hardware-related complications [τ2=0.000; χ2=4.922, df=10 (p=0.896); I2=0.0%], neurological complications [τ2=0.000; χ2=3.909, df=9 (p=0.917); I2=0.0%], surgical-site complications [τ2=0.000; χ2=5.232, df=8 (p=0.732); I2=0.0%], and overall complication rates [τ2=0.000; χ2=16.605, df=29 (p=0.968); I2=0.0%]. df, degrees of freedom; OR, odds ratio; CI, confidence interval.

• 

  Fig. 5 Comparison of infection rates between minimally invasive and open lumbar spinal fusion. Heterogeneity: τ2=0.000; χ2=2.197, df=6 (p=0.901); I2=0.0%. df, degrees of freedom; CI, confidence interval; OR, odds ratio.

• 

  Fig. 6 Comparison of subsequent surgery rates between minimally invasive and open lumbar spinal fusion. Heterogeneity: Removal [τ2=1.204; χ2=2.938, df=2 (p=0.230); I2=31.9%], reoperation [τ2=0.774; χ2=3.965, df=3 (p=0.265); I2=24.3%], revision [τ2=0.000; χ2=1.154, df=3 (p=0.764); I2=0.0%], overall subsequent surgery rates [τ2=0.000; χ2=8.565, df=10 (p=0.574); I2=0.0%]. df, degrees of freedom; OR, odds ratio; CI, confidence interval.

• 

  Fig. 7 Comparison of blood loss between minimally invasive and open lumbar spinal fusion. Heterogeneity: τ2=0.747; χ2=57.666, df=5 (p<0.0001); I2=91.3%. df, degrees of freedom; CI, confidence interval.

• 

  Fig. 8 Comparison of hospital stay, operation time, and radiation exposure time between minimally invasive and open lumbar spinal fusion. Heterogeneity: hospital stay [τ2=0.236; χ2=26.011, df=5 (p<0.0001); I2=80.8%], operation time [τ2=0.297; χ2=40.069, df=6 (p<0.0001); I2=85.0%], and radiation exposure time [τ2=0.240; χ2=14.309, df=3 (p=0.003); I2=79.0%]. df, degrees of freedom; CI, confidence interval.

Reference

1. Gaines RW Jr. The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am. 2000; 82-A:1458–1476. PMID: 11057475.

2. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM. A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine (Phila Pa 1976). 1994; 19(20 Suppl):2279S–2296S. PMID: 7817243.

3. Thomsen K, Christensen FB, Eiskjaer SP, Hansen ES, Fruensgaard S, Bünger CE. 1997 Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomized clinical study. Spine (Phila Pa 1976). 1997; 22:2813–2822. PMID: 9431617.

4. Bjarke Christensen F, Stender Hansen E, Laursen M, Thomsen K, Bünger CE. Long-term functional outcome of pedicle screw instrumentation as a support for posterolateral spinal fusion: randomized clinical study with a 5-year follow-up. Spine (Phila Pa 1976). 2002; 27:1269–1277. PMID: 12065973.

5. Sihvonen T, Herno A, Paljärvi L, Airaksinen O, Partanen J, Tapaninaho A. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine (Phila Pa 1976). 1993; 18:575–581. PMID: 8484148.

6. Rantanen J, Hurme M, Falck B, Alaranta H, Nykvist F, Lehto M, et al. The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine (Phila Pa 1976). 1993; 18:568–574. PMID: 8484147.

7. Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg. 2002; 97(1 Suppl):7–12. PMID: 12120655.

8. Kim DY, Lee SH, Chung SK, Lee HY. Comparison of multifidus muscle atrophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976). 2005; 30:123–129. PMID: 15626992.

9. Villavicencio AT, Burneikiene S, Roeca CM, Nelson EL, Mason A. Minimally invasive versus open transforaminal lumbar interbody fusion. Surg Neurol Int. 2010; 1:12. PMID: 20657693.

10. Sclafani JA, Kim CW. Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review. Clin Orthop Relat Res. 2014; 472:1711–1717. PMID: 24510358.

11. Park Y, Ha JW, Lee YT, Sung NY. Minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis and degenerative spondylosis: 5-year results. Clin Orthop Relat Res. 2014; 472:1813–1823. PMID: 23955260.

12. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA. 2000; 283:2008–2012. PMID: 10789670.

13. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009; 62:1006–1012. PMID: 19631508.

14. Cowley DE. Prostheses for primary total hip replacement. A critical appraisal of the literature. Int J Technol Assess Health Care. 1995; 11:770–778. PMID: 8567209.

15. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002; 21:1539–1558. PMID: 12111919.

16. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003; 327:557–560. PMID: 12958120.

17. Harbord RM, Harris RJ, Sterne JA. Updated tests for small-study effects in meta-analyses. Stata J. 2009; 9:197–210.

18. Wang HL, Lü FZ, Jiang JY, Ma X, Xia XL, Wang LX. Minimally invasive lumbar interbody fusion via MAST Quadrant retractor versus open surgery: a prospective randomized clinical trial. Chin Med J (Engl). 2011; 124:3868–3874. PMID: 22340311.

19. Parker SL, Mendenhall SK, Shau DN, Zuckerman SL, Godil SS, Cheng JS, et al. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg. 2014; 82:230–238. PMID: 23321379.

20. Wang J, Zhou Y, Feng Zhang Z, Qing Li C, Jie Zheng W, Liu J. Comparison of the clinical outcome in overweight or obese patients after minimally invasive versus open transforaminal lumbar interbody fusion. J Spinal Disord Tech. 2014; 27:202–206. PMID: 22614266.

21. Gu G, Zhang H, Fan G, He S, Cai X, Shen X, et al. Comparison of minimally invasive versus open transforaminal lumbar interbody fusion in two-level degenerative lumbar disease. Int Orthop. 2014; 38:817–824. PMID: 24240484.

22. Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012; 21:2265–2270. PMID: 22453894.

23. Mobbs RJ, Sivabalan P, Li J. Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies. J Clin Neurosci. 2012; 19:829–835. PMID: 22459184.

24. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Mid-term clinical results of minimally invasive decompression and posterolateral fusion with percutaneous pedicle screws versus conventional approach for degenerative spondylolisthesis with spinal stenosis. Eur Spine J. 2012; 21:1171–1177. PMID: 22173610.

25. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine. Eur Spine J. 2011; 20:623–628. PMID: 20927557.

26. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J. 2010; 19:1780–1784. PMID: 20411281.

27. Schizas C, Tzinieris N, Tsiridis E, Kosmopoulos V. Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience. Int Orthop. 2009; 33:1683–1688. PMID: 19023571.

28. Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009; 34:1385–1389. PMID: 19478658.

29. Park Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. Spine (Phila Pa 1976). 2007; 32:537–543. PMID: 17334287.