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

Affiliations
  • 1Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea. yungspine@gmail.com
  • 2Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.

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.


Cited by  1 articles

Comparison of Percutaneous versus Open Pedicle Screw Fixation for Treating Unstable Thoracolumbar Fractures
Jin Young Han, Ki Youn Kwon
J Korean Fract Soc. 2019;33(1):1-8.    doi: 10.12671/jkfs.2019.33.1.1.


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