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J Minim Invasive Spine Surg Tech > Volume 7(2); 2022 > Article
Dalton, Oyekan, Ridolfi, Gannon, Ruh, and Sharma: Minimally Invasive Transforaminal Lumbar Interbody Fusion with Enhanced Recovery after Surgery (ERAS): Early Experience with Initial Consecutive Cases at a Spine Naïve Community Hospital

Abstract

Objective

The objective of this study was to examine a spine naïve community hospital’s ability to perform MITLIF safely and with speedy discharge via implementation of a minimally invasive spine surgery (MISS) program utilizing ERAS.

Methods

Single community hospital retrospective cohort analysis for initial consecutive MITLIF cases with unilateral pedicle screws performed by a single surgeon from October 2019 to March 2021. Minimum postoperative follow-up was one year. Narcotic use was assessed per the state prescription drug monitoring program. Surgery protocol included single paraspinal incision, non-expandable 18/22 mm tube, operating microscope, fluoroscopic guidance, EMG with SSEP monitoring and Enhanced Recovery After Surgery (ERAS) protocol.

Results

52 patients were included. Average OR time, and fluoroscopy time were 143±115 minutes, and 1.00±0.47 minutes, respectively. Patients were prescribed an average of 38±33 post-operative opioid doses for an average of 8±7 days. All patients on preoperative, chronic narcotics had no prescription changes, pre-op versus post-op, despite clinical improvement. Complications included one irrigation a(1.9%) nd debridement with retention of hardware for surgical site infection, and one revision(1.9%) for displaced hardware. Discharge data included 47 (90.4%), four (7.7%), and one patients (1.9%) discharged on POD1, POD2, and beyond POD2, respectively.

Conclusion

MITLIF can be safely and successfully performed at a spine naïve community hospital with excellent intraoperative metrics, a low complication rate, and speedy discharge. MITLIF performed well in multiple perioperative and postoperative variables compared to MISS techniques. Considerations for implementation of MITLIF in the community setting include special equipment, personnel training, surgeon experience, ERAS protocols and diligent patient/indication selection.

INTRODUCTION

Minimally invasive spine surgery (MISS) is an area of active research aimed at improving patient outcomes compared to open spine surgery techniques. MISS approaches these goals by utilizing minimal openings and natural surgical planes to reduce surgical blood loss, perioperative anesthetic and analgesic requirements, and to preserve posterior motion segments and paraspinal muscles [1]. Developments in imaging guidance technology and instrumentation led to the introduction of a minimally invasive transforaminal lumbar interbody fusion (MITLIF) technique in 2002 [2,3]. The goal of the MITLIF approach is to avoid the destructive impact of the extensive retraction and muscular dissection required for a traditional open transforaminal lumbar interbody fusion (TLIF) [4,5].
Currently, there are limited large, high-quality studies directly comparing MISS and traditional open approaches in lumbar fusion surgery. In early investigations, however, MITLIF has performed well compared to open TLIF in terms of reduced morbidity [6-8]. Despite these advantages, a recent meta-analysis comparing MITLIF to open TLIF found a higher revision rate and readmission rate in the MIS group [9]. These risks, combined with expensive specialized equipment, and the substantial MISS learning curve have contributed to some spine surgeons noting implementation obstacles in their practice [9-12]. Additionally, there is a paucity of research regarding the ability of performing MITLIF in the outpatient setting and a lack of research regarding applying Enhanced Recovery After Surgery (ERAS) techniques to spine surgery [13,14]. ERAS protocols are multimodal perioperative care strategies aimed at accelerating post-surgical recovery by optimizing nutrition, standardizing analgesic/anesthetic regimens, and encouraging early mobilization [15-18]. ERAS holds significant promise for amplifying the benefits of MISS by reducing the direct and indirect cost and patient burden of inpatient postoperative care, but further study is needed [19].
Our study addresses these gaps in the current MISS literature by detailing our institution’s implementation of both a MISS program and an associated ERAS protocol at a small, previously spine-naïve, community hospital. Our goal was to demonstrate that MITLIF, combined with an ERAS protocol, could be successfully implemented in the community setting without pre-existing perioperative spine infrastructure. The primary hypothesis is that MITLIF can be effectively performed in this environment and will result in excellent perioperative outcomes, early discharge, and a low complication profile. The secondary hypothesis is that MITLIF will perform well in comparison to other minimally invasive techniques performed in the same setting, which includes minimally invasive direct lateral interbody fusion (MIDLIF) and minimally invasive laminectomy with posterolateral fusion (non-interbody fusion, NIF).

MATERIALS AND METHODS

This retrospective chart review study was approved by the Institutional Review Board at the University of Pittsburgh.

1. Study Design

We conducted a retrospective chart review (level IV) of the initial consecutive cases performed between October 2019 to March 2021 by a single fellowship-trained orthopaedic spine surgeon. The setting for all cases was a university-affiliated community hospital with no in-house spine experience for over 10 years prior to this study. Inclusion criteria were patients that underwent a minimally invasive lumbar fusion procedure. These procedures included MITLIF, minimally invasive direct lateral interbody fusion (MIDLIF), or non-interbody fusion (NIF). All included patients were reviewed for demographic information including age, BMI, co-morbidities, indication for surgery, and gender. Perioperative information collected included total operative time, total radiation (fluoroscopy) time, surgery performed, complications, estimated blood loss (EBL), and any need for return to the operating room. Post-operative information collected included narcotics prescribed, length of hospital-stay, discharge disposition, and whether additional home health care was needed. Patient preoperative narcotic use was obtained via the Pennsylvania Drug Monitoring Program (PDMP). All patients included in this study had at least one year of follow-up available for review.

2. Treatment and Perioperative Protocol

Protocols included failure of nonoperative treatment modalities, which included over the counter medications, physical therapy, and interventional pain management. Surgical intervention included individualized patient-procedure matching with shared decision-making and pre-operative surgeon-guided education with counselling. Surgical technique included paraspinal/minimally invasive lateral lumbar surgery approaches. Surgical equipment utilized included a non-expandable 18/22 mm beveled and slotted tubular retractor ports, an operating microscope, and fluoroscopic guidance. Spinal monitoring was performed via EMG with SSEP. Spinal monitoring was used in all cases. Intraoperative and perioperative care followed an Enhanced Recovery After Surgery (ERAS) protocol. All cases included layered closure with barbed suture to reduce dead space, a local anesthetic consisting of bupivacaine administered along the wound bed in multiple small wheals, and a glue mesh waterproof dressing. Cases were performed without foley catheters, surgical drains, post-operative in-hospital imaging, or in-hospital dressing changes. For all patients, hospital medicine and occupational and physical therapy services were consulted on post-operative day (POD) 0. Laboratory bloodwork obtained on POD 1 included a complete blood count with a basic metabolic panel. Pain treatment included cold therapy, acetaminophen, methocarbamol, and narcotics as needed for breakthrough pain. Chronic pain prescriptions were maintained unchanged throughout patient hospitalization. Post-operative outpatient clinic follow-up visits were performed at 2 weeks, 6–8 weeks, and 16–24 weeks.

3. Statistical Analysis

The study power was set to 80% with an α=0.05. There were no missing values. The p-values were calculated from the likelihood ratio chi-square test for categorical variables including the subgroup difference in gender. Unpaired two-tailed t-tests were used to calculate p-values for continuous variables including average operating room (OR) time between subgroups. Linear regression was used for bivariate analysis with BMI.

RESULTS

1. Demographics

In total, 98 patients met criteria for inclusion. Patients were subdivided by surgical procedure performed. Group One consisted of 52 patients (53.1%) who had undergone MITLIF. Group Two consisted of 12 patients (12.2%) who had undergone MIDLIF. Group Three consisted of 34 patients (34.7%) who had undergone NIF.
Intergroup demographic comparisons included MITLIF versus NIF (Table 1) and MITLIF versus MIDLIF (Table 2). Patients in the MITLIF group were significantly younger than patients in the NIF group (66±12 years versus 73±10 years, p=0.005). Patients in the MITLIF group were similar in terms of gender distribution compared to the NIF group (28 females [53.8%] and 24 males [46.2%] versus 23 females [67.6%] and 11 males [32.4%], p=0.203). Patients in the MITLIF group had a significantly higher average BMI than patients in the NIF group (31.6±5.6 versus 28.9±5.1, p=0.027).
Patients in the MITLIF group were of similar age compared to patients in the MIDLIF group (66±12 years versus 67±6 years, p=0.797). Patients in the MITLIF group were similar in terms of gender distribution compared to the MIDLIF group (28 females [53.8%] and 24 males [46.2%] versus 7 females [53.8%] and 5 males [41.7%], p=0.778). Patients in the MITLIF group had a similar average BMI compared to patients in the MIDLIF group (31.6±5.6 versus 34.2±6.6, p=0.217).

2. Intraoperative Data

Intergroup intraoperative comparisons included MITLIF versus NIF (Table 1) and MITLIF versus MIDLIF (Table 2). Patients in the MITLIF group had similar OR time (minutes) compared to the NIF group (143±115 minutes versus 118±28 minutes, p=0.131). Patients in the MITLIF group had similar EBL (mL) compared to the NIF group (72±44 mL versus 73±42 mL, p=0.736). Patients in the MITLIF group had significantly longer radiation time (minutes) compared to the NIF group (1.0±0.47 minutes versus 0.67±0.48 minutes, p=0.003). Patients in the MITLIF group experienced higher radiation dose (rad) compared to the NIF group (4.23±2.95 minutes versus 2.69±2.15 minutes, p=0.007).
Patients in the MITLIF group had similar OR time (minutes) compared to the MIDLIF group (143±115 minutes versus 190±81 minutes, p=0.114). Patients in the MITLIF group had similar EBL (mL) compared to the MIDLIF group (72±44 mL versus 78±58 mL, p=0.724). Patients in the MITLIF group had significantly less radiation time (minutes) compared to the MIDLIF group (1.0±0.47 minutes versus 1.81±1.11 minutes, p=0.028). Patients in the MITLIF group experienced similar radiation dose (rad) compared to the MIDLIF group (4.23±2.95 minutes versus 6.56±6.32 minutes, p=0.236).

3. Postoperative Data

Intergroup postoperative comparisons included MITLIF versus NIF (Table 1), and MITLIF versus MIDLIF (Table 2). The number of patients discharged in the MITLIF versus NIF groups was similar on POD 0 (MITLIF: 0 patients versus NIF: 0 patients), on POD 1 (MITLIF: 47 patients [90.4%] versus NIF: 31 patients [91.2%]), and on POD 2 (MITLIF: 4 patients [7.7%] versus NIF: 3 patients [8.8%], p=0.87). The average day of discharge was similar between groups (MITLIF: POD 1.2±0.9 versus NIF: POD 1.1±0.3, p=0.43). Discharge disposition did not differ significantly between MITLIF and NIF patients (MITLIF: 28 patients [53.8%] home with self-care, 24 patients [46.2%] home with RN/PT, 0 patients SNF versus NIF: 20 patients [58.8%] home with self-care, 12 patients [35.3%] home with RN/PT, 2 patients [5.9%] SNF, p=0.66, 0.38, 0.15, respectively). MITLIF patients required similar number of opioid doses (5 mg oxycodone tablet) postoperatively compared to NIF patients (38±33 versus 37±30, p=0.749). MITLIF patients required similar duration of opioid prescription postoperatively compared to NIF patients (8±7 days versus 8±7 days, p=0.808).
The number of patients discharged in the MITLIF versus MIDLIF groups was similar on POD 0 (MITLIF: 0 patients versus MIDLIF: 0 patients), on POD 1 (MITLIF: 47 patients [90.4%] versus MIDLIF: 9 patients [75%]), and on POD 2 (MITLIF: 4 patients [7.7%] versus MIDLIF: 3 patients [25%], p=0.089). The average day of discharge was similar between groups (MITLIF: POD 1.2±0.9 versus MIDLIF: POD 1.3±0.5, p=0.75). Discharge disposition did not differ significantly between MITLIF and MIDLIF patients (MITLIF: 28 patients [53.8%] home with self-care, 24 patients [46.2%] home with RN/PT, 0 patients SNF versus MIDLIF: 4 patients [33.3%] home with self-care, 8 patients [66.7%] home with RN/PT, 0 patients SNF, p=0.34). MITLIF patients required similar number of opioid doses (5 mg oxycodone tablet) postoperatively compared to MIDLIF patients (38±33 versus 46±32, p=0.47). MITLIF patients required similar duration of opioid prescription postoperatively compared to MIDLIF patients (8±7 days versus 9±5 days, p=0.79).
Of note, chronic opioid dependence did not change despite clinical improvement. There were 8 patients in the MITLIF group and 2 patients in the MIDLIF group taking chronic opioids pre-operatively who had no difference in post-operative chronic opioid prescriptions.

4. Bivariate Comparisons

Amongst MITLIF patients, radiation dose was directly correlated with BMI (R2=0.1321). EBL (R2=0.0865), OR time (R2=0.0035), and opioid dose (R2=0.0069) were not correlated with BMI.

5. Complications

Complications included one MITLIF patient (1.9%) who underwent an irrigation and debridement (hardware retained) for surgical site infection.

DISCUSSION

Key Findings

The primary hypothesis of this study is that MITLIF, combined with ERAS protocols, can be effectively performed in the community setting and result in excellent perioperative outcomes, early discharge, and a low complication profile. Our data largely supported this hypothesis. Patients undergoing MITLIF had low EBL (72±44 mL), with 90.4% of patients discharged on POD 1, and 100% of patients discharged to home. The secondary hypothesis in this study is that MITLIF will perform well in comparison to other minimally invasive techniques performed in the same setting, which was also supported by our data. The use of MITLIF did not significantly increase EBL, OR time, length of hospital stay, opioid dose, or opioid duration compared to patients undergoing NIF or MIDLIF.
A recent study performed in a large university setting, which compared MITLIF to open TLIF, reported a median length of hospitalization of 3 and 4 days, respectively (p=0.006) [8]. Of the three randomized controlled trials comparing MITLIF to open TLIF, only one specifically examined postoperative hospital length of stay, and did not find a significant difference (6.4±2.5 days versus 8.7±2.1 days, p=0.087) [20-22]. Thus, our data indicate that implementation of MISS with ERAS protocols at a community, previously spine-naïve hospital can produce excellent discharge disposition and timing after MITLIF, even compared to large academic centers. There is limited data regarding outcomes after truly “outpatient” MITLIF, and in this study, no patients were discharged after MITLIF on POD 0 [13]. However, given that the ERAS protocol was not specifically catered to drive outpatient discharge, and with the retrospective nature of the current data, it is difficult to speculate from this study on the ability to perform truly outpatient MITLIF. Given the very short average length of hospital stay and excellent outcomes, it may be reasonable to perform a prospective analysis in this setting examining outpatient MITLIF.
Average opioid dose and duration required for postoperative pain control was low (38±33 doses of 5 mg oxycodone for 8±7 days). A recent work comparing MITLIF to open TLIF reported postoperative opioid usage of 167 and 255 morphine milligram equivalents, respectively [23]. The total average opioid dosage required after MITLIF in this study, when converted to similar units, was lower, at 57±49.5 milligram morphine equivalents. Good pain control and the very low EBL in this study are likely in part from a rigorous implementation of ERAS protocols. One of the only studies examining the use of ERAS in the setting of MITLIF reported a significantly decreased length of stay and EBL in patients undergoing MITLIF with ERAS compared to patients undergoing the same surgery with conventional postoperative protocols [19]. A recent meta-analysis examining studies reporting data on operative time in MITLIF versus open TLIF did not find a significant difference, but did note significant heterogeneity between the studies [24]. Amongst the studies reported in this meta-analysis, the mean operative time in the MITLIF groups ranged from 104±26 minutes to 389.7±57 minutes [25,26]. Our reported average operative time of 143±115 minutes compares well to these averages. Amongst the studies reported in this meta-analysis, the mean blood loss reported in the MITLIF groups ranged from 50.6±161 mL to 466.7±199.4 mL [25,27]. Our reported average EBL of 72±44 mL compares well to these averages. Thus, in terms of postoperative pain control, operative time and EBL, our data indicate that MITLIF can be safely and effectively performed in a small community hospital with no prior spine experience.
The wide range of data reported in the MITLIF regarding important intraoperative and perioperative variables can partially be attributed to a commonly cited shallow “learning curve” that exists in MISS in general, and especially for MITLIF [9,11,28-30]. The main reported impacts of this learning curve are on operative time and rate of complications. A recent study that mapped the MITLIF learning curve data to a negative exponential function reported that 90% of expert level operative time was achieved at case 39 [11]. Over this same time span, the complication rate dropped from 33% to 20.5% [11]. Additionally, due to a likely selection bias stemming from surgeons frequently electing to operate on simpler cases in the early stages of their experience with MISS, the impact of the learning curve in MISS is possibly underreported [3,31]. With these factors in mind, it is important to note that the operative surgeon in our study has been performing MISS for over 10 years. Thus, although the surgical center itself and the perioperative staff from our study were naïve to spine surgery, the operative surgeon is well past the learning curve reported for MISS in the literature.
The strengths of this study include that all cases were performed by a single surgeon at a single surgical center, which decreases confounding variables related to differing surgeon experience level, differing operative techniques, and differing perioperative staff. The weaknesses of this study include the significantly higher average age and significantly lower BMI of the NIF Group compared to the MITLIF Group, making direct comparisons between these two groups somewhat difficult. These differences were due to the retrospective nature of this analysis. A higher BMI, in particular, has been cited in the MISS literature as leading to increased radiation exposure. This was consistent with our findings when comparing the higher BMI MITLIF Group, which had significantly higher radiation time and dose, to the lower BMI NIF Group. However, while this body habitus difference did not appear to impact operative time, nor EBL, the differing age makes these findings difficult to fully interpret at this time.

CONCLUSION

This is the first data collected from a series of MITLIF cases performed after the establishment of an MISS program with ERAS perioperative care in a previously spine-naïve setting. It demonstrates the ability of a single surgeon, who is past the MISS learning curve, to achieve an excellent safety profile both in the intraoperative setting, upon discharge to home, and within a year of surgery, with excellent pain control after MITLIF with ERAS protocols.

NOTES

Ethical statements

This retrospective chart review study was approved by the Institutional Review Board at the University of Pittsburgh.

Conflicts of interest

No potential conflict of interest relevant to this article.

Table 1.
Intergroup comparisons between minimally invasive transforaminal interbody fusion (MITLIF) versus laminectomy with posterolateral fusion without interbody fusion (NIF)
MITLIF versus laminectomy with NIF
MITLIF NIF p-value
Baseline patient characteristics
 # of subjects 52 (53.1%) 34 (34.7%)
 Age (yr) 66±12 73±10 0.005*
 Female (%) 28 (54%) 23 (68%) 0.203
 BMI 31.6±5.6 28.9±5.1 0.027*
Co-morbidities
 Hypertension 31 (59.6%) 23 (67.6%)
 DM 11 (21.2%) 10 (29.4%)
 COPD 1 (1.9%) 2 (5.9%)
 CAD 3 (5.8%) 3 (8.8%)
 GERD 15 (28.8%) 7 (20.6%)
 Tobacco use 6 (11.5%) 0
 History of DVT 3 (5.8%) 1 (2.9%)
Indication for surgery
 Stenosis 45 (86.5%) 34 (100%)
 Spondylolisthesis 39 (75%) 13 (38.2%)
 Disc herniation 12 (23.1%) 3 (8.8%)
Procedural details
 OR time (min) 143±115 118±28 0.131
 EBL (mL) 72±44 73±42 0.736
 Radiation time (min) 1.00±0.47 0.67±0.48 0.003*
 Radiation dose (rad) 4.23±2.95 2.69±2.15 0.007*
Post-operative day of discharge
 0 0 0
 1 47 (90.4%) 31 (91.2%)
 2 4 (7.7%) 3 (8.8%)
 >2 1 (1.9%) 0
 Avg 1.2±0.9 1.1 ± 0.3 0.425
Discharge disposition
 Home w/self-care 28 (53.8%) 20 (58.8%)
 Home w/RN/PT 24 (46.2%) 12 (35.3%)
 SNF 0 2 (5.9%)
Opioid use (per state PDMP)
 # opioid doses prescribed (5 mg oxycodone) 38±33 37 ± 30 0.749
 Duration of opioid prescription (d) 8±7 8±7 0.808
Table 2.
Intergroup comparisons between minimally invasive transforaminal interbody fusion (MITLIF) versus minimally invasive direct lateral interbody fusion (MIDLIF)
MITLIF versus MIDLIF
TLIF MIDLIF p-value
Baseline patient characteristics
 # of subjects 52 (53.1%) 12 (12.2%)
 Age (yr) 66±12 67±6 0.797
 Female (%) 28 (54%) 7 (58%) 0.778
 BMI 31.6±5.6 34.2±6.6 0.217
Co-morbidities
 Hypertension 31 (59.6%) 7 (58.3%)
 Diabetes mellitus 11 (21.2%) 2 (16.7%)
 COPD 1 (1.9%) 1 (8.3%)
 CAD 3 (5.8%) 1 (8.3%)
 GERD 15 (28.8%) 1 (8.3%)
 Tobacco use 6 (11.5%) 0
 History of DVT 3 (5.8%) 0
Indication for surgery
 Stenosis 45 (86.5%) 12 (100%)
 Spondylolisthesis 39 (75%) 7 (58.3%)
 Disc herniation 12 (23.1%) 0
Procedural details
 OR time (min) 143±115 190±81 0.114
 EBL (mL) 72±44 78±58 0.724
 Radiation time (min) 1.0±0.47 1.81±1.11 0.028*
 Radiation dose (rad) 4.23±2.95 6.56±6.32 0.236
Post-operative day of discharge
 0 0 0
 1 47 (90.4%) 9 (75%) 0.089
 2 4 (7.7%) 3 (25%)
 >2 1 (1.9%) 0
 Avg 1.2±0.9 1.3±0.5 0.747
Discharge disposition
 Home with self-care 28 (53.8%) 4 (33.3%)
 Home with RN or PT 24 (46.2%) 8 (66.7%)
 SNF 0 0
Opioid use (per state PDMP)
 Number of opioid doses prescribed 38±33 46±32 0.470
 Duration of opioid prescription (d) 8±7 9±5 0.787

REFERENCES

1. Banczerowski P, Czigléczki G, Papp Z, Veres R, Rappaport HZ, Vajda J. Minimally invasive spine surgery: systematic review. Neurosurg Rev 2015 38:11–26. discussion 26.
crossref pmid pdf
2. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976) 2003;28:S26–S35.
crossref pmid
3. Sharif S, Afsar A. Learning curve and minimally invasive spine surgery. World Neurosurg 2018;119:472–478.
crossref pmid
4. Gejo R, Matsui H, Kawaguchi Y, Ishihara H, Tsuji H. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine (Phila Pa 1976) 1999;24:1023–1028.
crossref pmid
5. 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.
crossref pmid
6. Kim JS, Jung B, Lee SH. Instrumented minimally invasive spinal-transforaminal lumbar interbody fusion (MIS-TLIF): minimum 5-year follow-up with clinical and radiologic outcomes. Clin Spine Surg 2018;31:E302–E309.
pmid
7. Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang X. Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach. Eur Spine J 2010;19:316–324.
crossref pmid pdf
8. 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.
crossref pmid
9. Jin-Tao Q, Yu T, Mei W, Xu-Dong T, Tian-Jian Z, Guo-Hua S, et al. Comparison of MIS vs. open PLIF/TLIF with regard to clinical improvement, fusion rate, and incidence of major complication: a meta-analysis. Eur Spine J 2015;24:1058–1065.
crossref pmid pdf
10. Lewandrowski KU, Soriano-Sánchez JA, Zhang X, Ramírez León JF, Soriano Solis S, Rugeles Ortíz JG, et al. Surgeon motivation, and obstacles to the implementation of minimally invasive spinal surgery techniques. J Spine Surg 2020;6:S249–S259.
crossref pmid pmc
11. Silva PS, Pereira P, Monteiro P, Silva PA, Vaz R. Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus 2013;35:E7.
crossref
12. Lee KH, Yeo W, Soeharno H, Yue WM. Learning curve of a complex surgical technique: minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). J Spinal Disord Tech 2014;27:E234–E240.
pmid
13. Basil GW, Wang MY. Trends in outpatient minimally invasive spine surgery. J Spine Surg 2019;5:S108–S114.
crossref pmid pmc
14. Parrish JM, Jenkins NW, Brundage TS, Hrynewycz NM, Podnar J, Buvanendran A, et al. Outpatient minimally invasive lumbar fusion using multimodal analgesic management in the ambulatory surgery setting. Int J Spine Surg 2020;14:970–981.
crossref pmid
15. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change practice. Can Urol Assoc J 2011;5:342–348.
crossref pmid pmc
16. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–617.
crossref pmid
17. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466–477.
crossref pmid
18. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006;25:224–244.
crossref pmid
19. Wang MY, Chang HK, Grossman J. Reduced acute care costs with the ERAS® Minimally invasive transforaminal lumbar interbody fusion compared with conventional minimally invasive transforaminal lumbar interbody fusion. Neurosurgery 2018;83:827–834.
crossref pmid pdf
20. 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.
crossref pmid pdf
21. 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
22. Rodríguez-Vela J, Lobo-Escolar A, Joven E, Muñoz-Marín J, Herrera A, Velilla J. Clinical outcomes of minimally invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3- to 4-year follow-up. Eur Spine J 2013;22:2857–2863.
crossref pmid pmc pdf
23. Hockley A, Ge D, Vasquez-Montes D, Moawad MA, Passias PG, Errico TJ, et al. Minimally invasive versus open transforaminal lumbar interbody fusion surgery: an analysis of opioids, nonopioid analgesics, and perioperative characteristics. Global Spine J 2019;9:624–629.
crossref pmid pmc pdf
24. Tian NF, Wu YS, Zhang XL, Xu HZ, Chi YL, Mao FM. Minimally invasive versus open transforaminal lumbar interbody fusion: a meta-analysis based on the current evidence. Eur Spine J 2013;22:1741–1749.
crossref pmid pmc pdf
25. Lau D, Lee JG, Han SJ, Lu DC, Chou D. Complications and perioperative factors associated with learning the technique of minimally invasive transforaminal lumbar interbody fusion (TLIF). J Clin Neurosci 2011;18:624–627.
crossref pmid
26. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery 2007 60(4 Suppl 2):203–212. discussion 212-213.
crossref pmid
27. 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.
crossref pmid pmc pdf
28. 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.
crossref pmid pdf
29. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: our experience in 86 consecutive cases. Spine (Phila Pa 1976) 2012;37:1548–1557.
pmid
30. Benzel EC, Orr RD. A steep learning curve is a good thing! Spine J 2011;11:131–132.
crossref pmid
31. 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.
crossref pmid pmc
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