Posterior lumbar fusion [Neurosurgery Wiki]

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====== Posterior lumbar fusion ======

Cloward 
((Cloward RB. The degenerated lumbar disc: treatment by vertebral body fusion. J Int Coll Surg. 1954;22(4 Sect. 1):375–86.)) 
is credited with championing the [[posterior lumbar fusion]] in [[1940]].
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[[Posterior lumbar interbody fusion]](PLIF)

[[Posterolateral Lumbar Fusion]]

[[Transforaminal lumbar interbody fusion]](TLIF)


A [[systematic review]] of the [[Medline]], [[EMBASE]], [[PubMed]], [[Web of Science]], and [[Cochrane]] [[database]]s was performed. A hand search of reference lists was conducted. Studies were reviewed by 2 independent assessors to identify [[randomized controlled trial]]s (RCTs) or comparative [[cohort]] studies including at least 10 patients undergoing [[MIS]] or open [[TLIF]]/[[PLIF]] for [[degenerative lumbar spine disorder]]s and reporting at least 1 of the following: [[clinical outcome measure]], perioperative clinical or process measure, radiographic outcome, or adverse events. Study quality was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) protocol. When appropriate, a meta-analysis of outcomes data was conducted. 

The systematic review and reference list search identified 3301 articles, with 26 meeting study inclusion criteria. All studies, including 1 RCT, were of low or very low quality. No significant difference regarding age, sex, surgical levels, or diagnosis was identified between the 2 cohorts (856 patients in the MIS cohort, 806 patients in the open cohort). The meta-analysis revealed changes in the perioperative outcomes of mean estimated blood loss, time to ambulation, and length of stay favoring an MIS approach by 260 ml (p < 0.00001), 3.5 days (p = 0.0006), and 2.9 days (p < 0.00001), respectively. Operative time was not significantly different between the surgical techniques (p = 0.78). There was no significant difference in surgical adverse events (p = 0.97), but MIS cases were significantly less likely to experience medical adverse events (risk ratio [MIS vs open] = 0.39, 95% confidence interval 0.23-0.69, p = 0.001). No difference in nonunion (p = 0.97) or reoperation rates (p = 0.97) was observed. Mean [[Oswestry Disability Index]] scores were slightly better in the patients undergoing MIS (n = 346) versus open TLIF/PLIF (n = 346) at a median follow-up time of 24 months (mean difference [MIS - open] = 3.32, p = 0.001).

The result of this quantitative systematic review of clinical comparative effectiveness research examining MIS versus open TLIF/PLIF for degenerative lumbar pathology suggests equipoise in patient-reported clinical outcomes. Furthermore, a meta-analysis of adverse event data suggests equivalent rates of surgical complications with lower rates of medical complications in patients undergoing minimally invasive TLIF/PLIF compared with open surgery. The quality of the current comparative evidence is low to very low, with significant inherent bias.