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1. Local zone of injury—less extensive collateral damage or muscle injury because of the approach Less area or zone of injury as assessed by postoperative cross-sectional MRI Less selective type II fiber atrophy on postoperative muscle biopsy Lower physiologic cross-sectional area reflecting less muscle strength Lower incidence of postoperative intracompartmental pressure, decreased perfusion, and lower oxygen saturation of the paraspinal muscle compartment Less intramuscular edema Less postoperative muscle atrophy of the multifidus, interspinales, intertransversarii, longissimus, and iliocostalis documented on muscle biopsy or less denervation by EMG Postoperative muscle biopsy specimens showing a lower incidence of denervation, fibrosis, and fatty infiltration Lower incidence of local neurologic injury (free-running EMG, MEP, SSEP) and less denervation of paraspinal musculature Lower incidence of intercostal neuralgia, less decrease of sympathetic trunk function, and less development of reflex sympathetic dystrophies Lower incidence of epidural scar formation Reduced anterior abdominal dissection and less vascular retraction particularly with multilevel procedures 2. Operative patient demographics that are directly dependent on the approach Less intraoperative estimated blood loss Shorter length of surgical time Shorter fluoroscopy time and less radiation exposure Lower amounts of wound drainage Lower incidence of postoperative seroma formation Fewer intraoperative complications or adverse events (dural tears, medical complications, and so on) Greater preservation of spinal stability by preservation of anterior and posterior longitudinal ligaments No or acceptable loss of sagittal or coronal balance Smaller zone of muscle injury or necrosis measured by creatine kinase and aldolase levels. Is there a decrease in levels of inflammatory cytokines (IL-6, IL-8, IL-10, IL-1) compared with previous techniques? Lower incidence of SSIs (Table 2) 3. Patient and hospitalization demographics that are indirectly related to the approach Shorter length of hospital stay Shorter length of stay in intensive care unit Shorter length of stay in rehabilitation hospital or skilled nursing facility Shorter length of time in medically supervised physical therapy before transition to self-motivated physical fitness Timing of neurologic decompression, particularly with staged front and back procedures Outcome instruments (VAS, ODI, ZCQ, SF-36, ASIA score) Fewer intrahospital complications, including medical and comorbidities Lower incidence of reoperations 4. Econometrics or global cost to society Faster return to work with less economic expenditures Improved QALYs with shorter estimated blood loss, LOS, and hospital time, without sacrificing patient outcome instruments (NDI, ODI, VAS, and so on) More favorable incremental cost-effectiveness ratios (ie, change in cost/change in effectiveness or cost per QALY) MIS is a procedure that requires more dependence on radiographic imaging and intraoperative navigation for intraoperative orientation for the surgeon Lower cost of spinal instrumentation and spinal implants Less costs for intraoperative surgical navigation Cost of radiographic imaging and intraoperative CT scanning Cost of optical magnification, endoscopes, and microscopes Cost of patient being lost to the workforce Lost opportunity costs Learning curve of MIS and time spent adopting new MIS techniques in instructional cadaveric courses Ability to expand indications to include additional surgical treatment groups, such as the elderly (higher BMI, more immunocompromised, more osteoporotic, more comorbidities) Abbreviations: ASIA, American Spinal Injury Association; BMI, body mass index; CT, computed tomography; EMG, electromyography; IL, interleukin; LOS; length of stay; MEP, motor evoked potentials; MRI, magnetic resonance imaging; NDI, Neck Disability Index; ODI, Oswestry Disability Index; QALY, quality-adjusted life-year; SF-36, Short Form 36; SSEP, somatosensory evoked potentials; VAS, visual analog scale; ZCQ, Zurich Claudication Questionnaire.
Authors N Predominant type of spine surgery No. of postoperative spine infections Ratio Incidence of infection Open spine procedures Spangfort14 10,104 Lumbar laminectomies 290 290/10,104 2.9% Smith et al.15 94,115 Posterior spinal fusions 2,280 2,280/94,115 2.4% Daubs et al.16 46 Spinal deformity posterior instrumentation 2 2/46 4.3% MIS spine procedures Perez-Cruet et al.17 150 Microendoscopic discectomy (MED) 0 0/150 0% Schwender et al.18 49 MIS TLIF 0 0/49 0% Selznick et al.19 43 MIS TLIF 0 0/43 0% O'Toole et al.3 1,338 Mixed—78% simple decompressions, 20% instrumented arthrodesis 3 3/1,338 0.22% Matched series (open + MIS) Rodgers and Michitsch12 144 Instrumented posterior lumbar fusions 6 6/144 4.2% Rodgers et al.13 313 XLIF 0 0/313 0% Rovner et al.20 251 Open TLIF 9 9/251 3.6% Rovner et al.20 196 MIS TLIF 0 0/196 0% Isaacs et al.21 29 XLIF with open posterior instrumentation 3 3/29 10% Isaacs et al. 21 78 XLIF and XLIF with MIS posterior instrumentation 0 0/78 0% Smith et al.15 94,115 Deep infections, all open cases 1,414 1,414/94,115 1.5% Smith et al.15 35 Deep infections, all MIS cases 14,301 35/14,301 0.2% Abbreviations: TLIF, transforaminal lumbar interbody fusion; XLIF, extreme lateral interbody fusion.
Infections Author Exposure Approach Procedure Indication No. of levels Levels N Simple decompression Instrumented decompression Instrumented fusion Total Rodgers et al. 23 MIS Lateral, posterior XLIF Stenosis with instability 1–4 L1-L5 600 — — 0.0% 0.0% Dakwar et al. 24 MIS Lateral, posterior XLIF Scoliosis 1–6 T10-S1 25 — — 0.0% 0.0% O'Toole et al. 3 MIS Mixed Mixed Mixed 1–4 C, T, L 1,338 0.0% 0.44% 0.74% 0.22% Dhall et al. 22 MIS Posterior TLIF DDD 1 L 21 — — 0.0% 0.0% Villavicencio et al. 25 MIS Posterior TLIF DDD 1–2 L 73 — — 1.3% 1.3% McAfee et al. 26 Endoscopic Anterior Decompression/fusion Mixed Mixed L 100 — — 0.0% 0.0% Brau et al. 27 MIS Anterior ALIF DDD 1 L 686 — — 0.4% 0.4% Dhall et al.22 Open Posterior TLIF DDD 2 L 21 — — 0.0% 0.0% Rihn et al.28 Open Posterior TLIF DDD 1 L 119 — — 6.1% 6.1% Fasciszewski et al.29 Open Anterior Anterior surgery Mixed Mixed C, T, L 1,223 — — — 1.6% Villavicencio et al.25 Open Posterior TLIF DDD 1–2 L 51 — — 1.6% 1.6% Jutte et al.30 Open Posterior PLF DDD 1–7 L 105 — 4.7% — 4.7% Villavicencio et al.25 Open Anterior ALIF DDD 1–2 L 43 — — 9.3% 9.3% Epstein et al.31 Open Posterior PLF DDD Mixed L 128 — — 10.9% 10.9% Abbreviations: ALIF, anterior lumbar interbody fusion; C, cervical; DDD, degenerative disc disease; L, lumbar; MIS, minimally invasive spine surgery; N, sample size; PLF, posterolateral fusion; T, thoracic; TLIF, transforaminal lumbar interbody fusion; XLIF, extreme lateral interbody fusion.
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