Elsevier

World Neurosurgery

Volume 83, Issue 5, May 2015, Pages 860-866
World Neurosurgery

Peer-Review Report
A 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?

https://doi.org/10.1016/j.wneu.2014.12.034Get rights and content

Background

Obese and morbidly obese patients undergoing lumbar spinal fusion surgery are a challenge to the operating surgeon. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open-TLIF have been performed for many years with good results; however, functional outcomes after lumbar spine surgery in this subgroup of patients remain poorly understood. Furthermore, whether index MIS-TLIF or open-TLIF for the treatment of degenerative disc disease or spondylolisthesis in morbidly obese results in superior postoperative functional outcomes remains unknown.

Methods

A total of 148 (MIS-TLIF: n = 40, open-TLIF: n = 108) obese and morbidly obese patients undergoing index lumbar arthrodesis for low back pain and/or radiculopathy between January 2003 and December 2010 were selected from a multi-institutional prospective data registry. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years. Patients completed the Oswestry Disability Index (ODI), Medical Outcomes Study Short-Form 36 (SF-36), and back and leg pain numerical rating scores before surgery and then at 12 and 24 months after surgery. Clinical outcomes and complication rates were compared between both patient cohorts.

Results

Compared with preoperative status, Visual Analog Scale (VAS) back and leg pain, ODI, and SF-36 physical component score/mental component score were improved in both groups. Both MIS-TLIF and open-TLIF patients showed similar 2-year improvement in VAS for back pain (MIS-TLIF: 2.42 ± 3.81 vs. open-TLIF: 2.33 ± 3.67, P = 0.89), VAS for leg pain (MIS-TLIF: 3.77 ± 4.53 vs. open-TLIF: 2.67 ± 4.10, P = 0.18), ODI (MIS-TLIF: 11.61 ± 25.52 vs. open-TLIF: 14.88 ± 22.07, P = 0.47), and SF-36 physical component score (MIS-TLIF: 8.61 ± 17.72 vs. open-TLIF: 7.61 ± 15.55, P = 0.93), and SF-36 mental component score (MIS-TLIF: 4.35 ± 22.71 vs. open-TLIF: 5.96 ± 21.09, P = 0.69). Postoperative complications rates between both cohorts were also not significantly divergent between (12.50% vs. 11.11%, P = 0.51).

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.

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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    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.

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