Peer-Review ReportA Prospective, Multi-Institutional Comparative Effectiveness Study of Lumbar Spine Surgery in Morbidly Obese Patients: Does Minimally Invasive Transforaminal Lumbar Interbody Fusion Result in Superior Outcomes?
Introduction
The prevalence of obesity in the United States is high, exceeding 30% in most age and sex groups (17). Numerous studies have demonstrated a strong association between obesity and medical resource use for low back pain and chronic low back pain 10, 11, 14, 15, 31, 34, 35. Although many obese patients with spinal stenosis are effectively treated nonoperatively (33), many patients do not respond to conservative treatments; furthermore, there is growing evidence that long-term outcomes may be inferior to nonoperative treatment modalities (27). Obese (body mass index [BMI] >30) and morbidly obese (BMI >35) patients undergoing lumbar spinal fusion surgery present a unique challenge to the spine surgeon because of poor operative corridors and difficult access to necessary anatomical landmarks. Collectively, these may contribute to increased risk of intraoperative complications (e.g., malpositioned pedicle screw, incidental durotomy, wrong-level surgery) 18, 21.
Transforaminal lumbar interbody fusion (TLIF) remains the gold standard for surgical decompression and fusion in patients with medically refractory lumbar stenosis and has been shown to have good long-term effectiveness 1, 20, 29. In nonobese patients, both minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open-TLIF have been shown to have good long-term clinical outcomes with equivocal results (28). Whether MIS-TLIF or open-TLIF procedures for treatment of degenerative disc disease (DDD) or spondylolisthesis result in superior postoperative functional outcomes in this subset of patients remains unknown.
The primary aim of this study is to assess and compare the long-term patient-reported outcomes after MIS-TLIF and open-TLIF procedures for treatment of symptomatic DDD or spondylolisthesis in obese and morbidly obese patients.
Section snippets
Study Design
From January 2003 to December 2010, we queried a prospectively maintained data registry that included consecutive patients who underwent lumbar spine surgery by one of a cohort of 106 neurosurgeons or orthopedic surgeons from 41 different institutions in the United States and Canada. Institutional review board approval was obtained from all 41 institutions.
Patient Selection
We included patients ages 18–70 years old with 1) low back pain and/or radiculopathy; 2) evidence on magnetic resonance imaging of DDD or
Results
From January 2003 to December 2010, a large, multicenter spine registry was queried, and on the basis of our inclusion and exclusion criteria, 148 obese and morbidly obese patients were enrolled in the study. We included patients between 18 and 70 years of age who had both clinical and radiographic indications for lumbar spinal fusion with available 1- and 2-year follow-up data. We excluded patients whose data came from institutions that contributed <60% of their spine surgeries to the
Discussion
In this multi-institutional study assessing long-term functional outcomes after MIS-TLIF versus open-TLIF procedures in obese and morbidly obese patients, we observed no difference in patient-reported outcomes of back pain, leg pain, or functional status, 1 and 2 years after index lumbar arthrodesis. Furthermore, there was no statistically significant difference in the incidence of postoperative complications between both groups. These findings should be helpful to surgeons when counseling
Conclusion
MIS-TLIF is a safe and viable option for lumbar fusion in morbidly obese patients, and compared with open-TLIF, resulted in similar improvement in pain and functional disability. Postoperative complications rates between both cohorts were also not significantly divergent.
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2020, Spine JournalCitation Excerpt :MIS techniques, compared with conventional open procedures, however, may provide similar outcomes while decreasing incision length, blood loss, operative time, and length of stay [63]. Adogwa et al. reviewed patients with BMI >30 and demonstrated similar improvement in pain, functional disability, and complication rates when comparing elective open versus MIS-transforaminal lumbar interbody fusion (TLIF) for degenerative disk disease or Grade I spondylolisthesis with central or foraminal stenosis who failed medical management [64]. Similar TLIF results were seen by Lau et al. in which obese patients had equivalent clinical outcomes and complication rates compared patients with normal weight [65].
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.