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Phillips F.M.,Rush University Medical Center | Isaacs R.E.,Duke University | Rodgers W.B.,Spine Midwest Inc. | Khajavi K.,Georgia Spine and Neurosurgery Center | And 6 more authors.
Spine | Year: 2013

Study Design. Prospective, multicenter, single-arm study. Objective. The objective of this study was to evaluate the clinical and radiographical results of patients undergoing extreme lateral interbody fusion (XLIF), a minimally disruptive lateral transpsoas retroperitoneal surgical approach for the treatment of degenerative scoliosis (DS). Summary of Background Data. Surgery for the treatment of DS has been reported to have acceptable results but is traditionally associated with high morbidity and complication rates. A minimally disruptive lateral transpsoas retroperitoneal surgical approach (XLIF) has become popular for the treatment of DS. This is the first prospective, multicenter study to quantify outcomes after XLIF in this patient population. Methods. A total of 107 patients with DS who underwent the XLIF procedure with or without supplemental posterior fixation at one or more intervertebral levels were enrolled in this study. Clinical and radiographical results were evaluated up to 24 months after surgery. Results. Mean patient age was 68 years; 73% of patients were female. A mean of 3.0 (range, 1-6) levels were treated with XLIF per patient. Overall complication rate was low compared with traditional surgical treatment of DS. Significant improvement was seen in all clinical outcome measures at 24 months: Oswestry Disability Index, visual analogue scale for back pain and leg pain, and 36-Item Short Form Health Survey mental and physical component summaries ( P < 0.001). Eighty-five percent of patients were satisfied with their outcome and would undergo the procedure again. In patients with hypolordosis, lumbar lordosis was corrected from a mean of 27.7 ° to 33.6 ° at 24 months ( P < 0.001). Overall Cobb angle was corrected from 20.9 ° to 15.2 ° , with the greatest correction observed in patients supplemented with bilateral pedicle screws. Conclusion. This study demonstrates the use of the XLIF procedure in the treatment of DS. XLIF is associated with good clinical and radiographical outcomes, with a substantially lower complication rate than has been reported with traditional surgical procedures. Copyright © 2013 Lippincott Williams & Wilkins.


Lucio J.C.,St Marys Health Center | van Conia R.B.,St Marys Health Center | de Luzio K.J.,Queen's University | Lehmen J.A.,Spine Midwest Inc | And 2 more authors.
Risk Management and Healthcare Policy | Year: 2012

Background: There is great debate about the costs and benefits of technology-driven medical interventions such as instrumented lumbar fusion. With most analyses using charge data, the actual costs incurred by medical institutions performing these procedures are not well understood. The object of the current study was to examine the differences in hospital operating costs between open and minimally invasive spine surgery (MIS) during the perioperative period. Methods: Data were collected in the form of a prospective registry from a community hospital after specific Institutional Review Board approval was obtained. The analysis included consecutive adult patients being surgically treated for degenerative conditions of the lumbar spine, with either an MIS or open approach for two-level instrumented lumbar fusion. Patient outcomes and costs were collected for the perioperative period. Hospital operating costs were grouped by hospitalization/operative procedure, transfusions, reoperations, and residual events (health care interactions). Results: One hundred and one open posterior lumbar interbody fusion (Open group) and 109 MIS patients were treated primarily for stenosis coupled with instability (39.6% and 59.6%, respectively). Mean total hospital costs were $27,055.53 for the Open group and $24,320.16 for the MIS group. This represents a statistically significant cost savings of $2,825.37 (10.4% [95% confidence interval: $522.51-$5,128.23]) when utilizing MIS over traditional Open techniques. Additionally, residual events, complications, and blood transfusions were significantly more frequent in the Open group, compared to the MIS group. Conclusions/level of evidence: Utilizing minimally invasive techniques for instrumented spinal fusion results in decreased hospital operating costs compared to similar open procedures in the early perioperative period. Additionally, patient benefits of minimally invasive techniques include significantly less blood loss, shorter hospital stays, lower complication rate, and a lower number of residual events. Long-term outcome comparisons are needed to evaluate the efficacy of the two treatments. Level of evidence: III Clinical relevance: This work represents a true cost-of-operating comparison between open and MIS approaches for lumbar spine fusion, which has relevance to surgeons, hospitals and payers in medical decision-making. © 2012 Hassan et al, publisher and licensee Dove Medical Press Ltd.


Isaacs R.E.,Duke University | Hyde J.,South Florida Spine Institute | Goodrich J.A.,Augusta Orthopaedic Clinic | Rodgers W.B.,Spine Midwest Inc | Phillips F.M.,Rush University Medical Center
Spine | Year: 2010

Study design.: Prospective multicenter nonrandomized institutional review board-approved observational study of clinical and radiographic outcomes of the extreme lateral interbody fusion (XLIF) procedure in adult scoliosis. Objective.: Perioperative measures from this longitudinal study were compiled to identify the short-term results and complications of the procedure. Summary of background data.: The surgical treatment of adult scoliosis presents a treatment challenge. Neural decompression with combined anterior/posterior instrumented fusion is often performed. These procedures have been reported to carry a high risk of complication, particularly in the elderly patient population. Over the past decade, less invasive surgical approaches to neural decompression and fusion have been popularized and have recently been applied in the treatment of degenerative scoliosis. To date, there has been little published data evaluating these treatment approaches. Methods.: A total of 107 patients who underwent the XLIF procedure with or without supplemental posterior fusion for the treatment of degenerative scoliosis were prospectively studied. Intraoperative data collection included surgical procedural details, operative time, estimated blood loss, and surgical complications. Postoperative complications, length of hospital stay, and neurologic status were recorded. For this report, perioperative data (inclusive of outcomes through the 6-week postoperative clinic visit) were evaluated. Results.: In all, 107 patients (mean age, 68 years; range, 45-87) were treated with XLIF; 28% had at least 1 comorbidity. A mean of 4.4 levels (range, 1-9) were treated per patient. Supplemental pedicle screw fixation was used in 75.7% of patients, 5.6% had lateral fixation, and 18.7% had stand-alone XLIF. Mean operative time and blood loss were 178 minutes (58 minutes/level) and 50 to 100 mL. Mean hospital stay was 2.9 days (unstaged), 8.1 day (staged, 16.5%), 3.8 days overall. Five patients (4.7%) received a transfusion, 3 (2.8%) required intensive care unit admission, and 1 (0.9%) required rehabilitation services. Major complications occurred in 13 patients (12.1%): 2 (1.9%) medical, 12 (11.2%) surgical. Of procedures that involved only less invasive techniques (XLIF stand-alone or with percutaneous instrumentation), 9.0% had one or more major complications. In those with supplemental open posterior instrumentation, 20.7% had one or more major complication. Early reoperations (3) (all for deep wound infections) were associated with open posterior instrumentation procedures. Conclusion.: The morbidity in adult scoliosis surgery is minimized with less invasive techniques. The rate of major complications in this study (12.1%) compares favorably to that reported from other studies of surgery for degenerative deformity. © 2010, Lippincott Williams & Wilkins.


Lehmen J.A.,Spine Midwest Inc. | Gerber E.J.,Spine Midwest Inc.
European Spine Journal | Year: 2015

Background: Over the past decade, the minimally disruptive lateral transpsoas approach for lumbar interbody fusion (MI-LIF) is increasingly being used as an alternative to conventional surgical approaches. The purpose of this review was to evaluate four primary questions as they relate to MI-LIF: (1) Is there an anatomical justification for MI-LIF at L4–5? (2) What are the complication and outcome profiles of MI-LIF and are they acceptable with respect to conventional approaches? (3) Given technical and neuromonitoring differences between various MI-LIF procedures, are there any published clinical differences? And, (4) are modern minimally disruptive procedures (e.g., MI-LIF) economically viable? Methods: Through a MEDLINE and Google Scholar search, a total of 237 articles that discussed MI-LIF were identified. Of those, topical areas included anatomy (22), biomechanics/testing (17), technical descriptions (11), case reports (40), complications (30), clinical and radiographic outcomes (43), deformity (23), trauma or thoracic applications (10), and review articles (41). Results: In answer to the questions posed, (1) there is a high strength of evidence showing MI-LIF to be anatomically justified at all levels of the lumbar spine from L1–2 to L4–5. The evidence also supports the use of advanced neuromonitoring modalities. (2) There is moderate strength evidence in support of reproducible and reasonable complication, side effect, and outcome profiles following MI-LIF which may be technique dependent. (3) There is low-strength evidence that shows elevated neural complication rates in non-traditional (e.g., shallow-docking approaches and/or those without specialized neuromonitoring) MI-LIF, and (4) there is low- to moderate-strength evidence that modern minimally disruptive surgical approaches are cost-effective. Conclusions: There is considerable published evidence to support MI-LIF in spinal fusion and advanced applications, though the results of some reports, especially concerning complications, vary greatly depending on technique and instrumentation used. Additional cost-effectiveness analyses would assist in fully understanding the long-term implications of MI-LIF. © 2015, Springer-Verlag Berlin Heidelberg.


Rodgers W.B.,Spine Midwest Inc. | Cox C.S.,Spine Midwest Inc. | Gerber E.J.,Spine Midwest Inc.
Journal of Spinal Disorders and Techniques | Year: 2010

Objectives: To compare between obese and nonobese patients, the incidence of early complications and predictive factors affecting complication rate. Summary of background data: XLIF is a 90-degree off midline approach that allows for large graft placement, excellent disk height restoration, and indirect decompression at the stenotic motion segment. As the psoas muscle is traversed, the lumbosacral plexus is protected by the use of automated electrophysiology through dynamic discrete evoked electromyogram thresholding. Exposure is achieved with an expandable split-blade retractor, which allows for direct illuminated visualization facilitating discectomy and complete anterior column stabilization by using a large load-bearing implant that rests on the dense ring apophysis bilaterally. Methods: A retrospective chart review of a prospectively compiled database of all patients treated with the XLIF procedure between October 2006 and July 2008 was completed. Early complications were defined as any adverse events occurring within the first 3 months of the index procedure. The National Institute of Health Guidelines for defining obesity relating to body mass index were used. Results: Out of 432 patients, 313 have complete data: 156 obese, 157 nonobese. The ages, comorbidities, earlier surgeries, and diagnoses were equivalent. There were no transfusions and no infections. Complications were minimal and about the same in each group. Conclusions: Unlike traditional open lumbar fusion procedures, minimally invasive surgery (XLIF) has no greater risk of complication in the obese patient. © 2010 by Lippincott Williams & Wilkins.


Rodgers W.B.,Spine Midwest Inc. | Gerber E.J.,Spine Midwest Inc. | Patterson J.,Spine Midwest Inc.
Spine | Year: 2011

Study Design. Prospective analysis of 600 extreme lateral interbody fusion (XLIF) approach procedures for intraoperative and perioperative complications. Objective. To delineate and describe complications in a large, prospective series of minimally invasive lateral lumbar fusion procedures (XLIF). Summary of Background Data. While some small series of lateral lumbar fusion have discussed complications, no results from large studies have been reported. Methods. A total of 600 patients were treated with a lateral approach to fusion (XLIF) for degenerative spinal conditions. Data were collected prospectively on all patients and analyzed for demographic, diagnostic, and hospitalization information to identify operative and early postoperative complications. Documented complication types and rates in this large series were compared with smaller prior reports on lateral approach fusions, as well as other minimally invasive (mini-anterior lumbar interbody fusion and minimally invasive surgical [MIS] transforaminal lumbar interbody fusion) and more traditional fusion approaches (posterior intertransverse fusion, anterior lumbar interbody fusion, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion). Results. Seven hundred forty-one levels were treated, 80.8% single level, 15.0% 2 level, 4.0% 3 level, 0.2% 4 level; 59.3%, including the L4 to L5 levels. A total of 99.2% included supplemental internal fixation; 83.2% included pedicle screw fixation (predominantly unilateral). Hemoglobin change from pre- to postoperation averaged 1.38. Hospital stay averaged 1.21 days. The overall incidence of perioperative complications (intraoperation and out to 6 weeks postoperation) was 6.2%: 9 (1.5%) in-hospital surgery-related events, 17 (2.8%) in-hospital medical events, 6 (1.0%) out-of-hospital surgery-related events, and 5 (0.8%) out-of-hospital medical events. There were no wound infections, no vascular injuries, no intraoperative visceral injuries, and 4 (0.7%) transient postoperative neurologic deficits. Eleven events (1.8%) resulted in additional procedures/reoperation. Conclusions. Compared with traditional open approaches, the MIS lateral approach to fusion by using the XLIF technique resulted in a lower incidence of infection, visceral and neurologic injury, and transfusion as well as markedly shorter hospitalization. Complications in MIS XLIF compare favorably with those from other MIS fusion procedures; duration of hospitalization is shorter than with any previously reported technique. Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


Rodgers W.B.,Spine Midwest Inc | Gerber E.J.,Spine Midwest Inc | Rodgers J.A.,Spine Midwest Inc
Spine | Year: 2010

Study design.: Retrospective chart review of prospectively collected data from 2 nonrandomized, nonconcurrent cohorts. Objective.: Early results of 2 lumbar interbody fusion procedures-open posterior lumbar interbody fusion (PLIF) and minimally invasive (extreme lateral interbody fusion [XLIF])-were compared in octogenarians to demonstrate the safety of each in the extreme elderly populations. Summary of background data.: Although spinal pathologies are common in the elderly patients, additional health conditions often preclude operative treatment because anesthesia, blood loss, and recovery are too demanding. Minimally invasive approaches reduce procedure-related morbidity and recovery time. Methods.: In our single-site prospective series of XLIF patients, 40 were identified as those aged ≥80 years with a minimum of 3-month follow-up. A complete, retrospective review of surgical patients treated in the same practice with traditional open posterior (PLIF) approach found 20 patients aged ≥80 years. Comparisons were made between groups to identify differences in morbidity and mortality rates. Results.: No clinically significant differences in demographics, diagnoses, or comorbidities were found between groups. Complication rate, blood loss/transfusion rate, and hospital stay were significantly lower in the minimally invasive surgery (MIS) group (P < 0.0001). MIS patients left the hospital an average of 4 days earlier than the open PLIF patients, most discharged home (92.5% XLIF vs. 0% PLIF) rather than to skilled nursing facilities. Six deaths occurred in the PLIF follow-up, 3 within 3 months postoperatively; there was 1 death at 6 months postoperatively XLIF. Conclusion.: Surgical treatment need not be withheld on the basis of age; elderly patients can successfully be treated using MIS techniques, and are-in our experience-among the most satisfied with their outcomes, enjoying significant improvements in pain, mobility, and quality of life. © 2010, Lippincott Williams & Wilkins.


Rodgers W.B.,Spine Midwest Inc. | Lehmen J.A.,Spine Midwest Inc. | Gerber E.J.,Spine Midwest Inc. | Rodgers J.A.,Spine Midwest Inc.
The Scientific World Journal | Year: 2012

Spondylolisthesis is one of the most common indications for spinal surgery. However, no one approach has been proven to be more effective in treating spondylolisthesis. Recent advances in minimally invasive spine technology have allowed for different approaches to be applied to this indication, notably extreme lateral interbody fusion (XLIF). The risk, however, of using XLIF in treating grade II spondylolisthesis is the ventral position of the lumbar plexus, particularly at L4-5. Objective. This study reports the safety and midterm clinical and radiographic outcomes of patients with grade II lumbar spondylolisthesis treated with XLIF. Methods. 63 patients with grade II spondylolisthesis and spinal stenosis were treated with XLIF and were available for 12-month followup. Of those, 61 (97) were treated at L4-5. Clinical (VAS, complications, and reoperation rate) and radiographic (anterolisthesis, disk height, and fusion) parameters were assessed. Study Design. Data were collected via a prospective registry and analyzed retrospectively. Results. Sixty-three patients were available for evaluations at least one year postoperatively. Average pain (visual analog scale) decreased from a score of 8.7 at baseline to 2.2 at 12 months postoperatively. Average anterior slippage was reduced by 73 and was well maintained. Average disk height (4.6 mm pre-op and 9.0 mm post-op) nearly doubled after surgery. Slight settling (average 1.3 mm) occurred over the twelve-month follow-up period. There were no neural injuries and no nonunions noted. Conclusions. XLIF is a safe and effective minimally invasive treatment alternative for grade II spondylolisthesis. Real-time neurological monitoring and attention to technique are mandatory. © 2012 W. B. Rodgers et al.


PubMed | University of California at San Diego, Johns Hopkins Hospital, Rush University Medical Center, Spine Midwest Inc. and Spine Institute of San Diego
Type: Journal Article | Journal: SAS journal | Year: 2015

The goal of this editorial and literature review is to define the term minimally invasive surgery (MIS) as it relates to the spine and characterize methods of measuring parameters of a spine MIS technique.This report is an analysis of 105,845 cases of spinal surgery in unmatched series and 95,161 cases in paired series of open compared with MIS procedures performed by the same surgeons to develop quantitative criteria to analyze the success of MIS.A lower rate of deep infection proved to be a key differentiator of spinal MIS. In unmatched series the infection rate for 105,845 open traditional procedures ranged from 2.9% to 4.3%, whereas for MIS, the incidence of infection ranged from 0% to 0.22%. For matched paired series with the open and MIS procedures performed by the same surgeons, the rate of infection in open procedures ranged from 1.5% to 10%, but for spine MIS, the rate of deep infection was much lower, at 0% to 0.2%. The published ranges for open versus MIS infection rates do not overlap or even intersect, which is a clear indication of the superiority of MIS for one specific clinical outcome measure (MIS proves superior to open spine procedures in terms of lower infection rate).It is difficult, if not impossible, to validate that an operative procedure is less invasive or more minimally invasive than traditional surgical procedures unless one can establish a commonly accepted definition of MIS. Once a consensus definition or precise definition of MIS is agreed upon, the comparison shows a higher infection rate with traditional spinal exposures versus MIS spine procedures.


PubMed | Spine Midwest Inc.
Type: | Journal: European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society | Year: 2015

Over the past decade, the minimally disruptive lateral transpsoas approach for lumbar interbody fusion (MI-LIF) is increasingly being used as an alternative to conventional surgical approaches. The purpose of this review was to evaluate four primary questions as they relate to MI-LIF: (1) Is there an anatomical justification for MI-LIF at L4-5? (2) What are the complication and outcome profiles of MI-LIF and are they acceptable with respect to conventional approaches? (3) Given technical and neuromonitoring differences between various MI-LIF procedures, are there any published clinical differences? And, (4) are modern minimally disruptive procedures (e.g., MI-LIF) economically viable?Through a MEDLINE and Google Scholar search, a total of 237 articles that discussed MI-LIF were identified. Of those, topical areas included anatomy (22), biomechanics/testing (17), technical descriptions (11), case reports (40), complications (30), clinical and radiographic outcomes (43), deformity (23), trauma or thoracic applications (10), and review articles (41).In answer to the questions posed, (1) there is a high strength of evidence showing MI-LIF to be anatomically justified at all levels of the lumbar spine from L1-2 to L4-5. The evidence also supports the use of advanced neuromonitoring modalities. (2) There is moderate strength evidence in support of reproducible and reasonable complication, side effect, and outcome profiles following MI-LIF which may be technique dependent. (3) There is low-strength evidence that shows elevated neural complication rates in non-traditional (e.g., shallow-docking approaches and/or those without specialized neuromonitoring) MI-LIF, and (4) there is low- to moderate-strength evidence that modern minimally disruptive surgical approaches are cost-effective.There is considerable published evidence to support MI-LIF in spinal fusion and advanced applications, though the results of some reports, especially concerning complications, vary greatly depending on technique and instrumentation used. Additional cost-effectiveness analyses would assist in fully understanding the long-term implications of MI-LIF.

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