A multicenter team of researchers from New York have looked into the upsides and downsides of multilevel minimally invasive (MIS) lumbar fusion.
Their work, “Diminishing Clinical Returns of Multilevel Minimally Invasive Lumbar Interbody Fusion,” appears in the October 15, 2019 edition of Spine.
Co-author Peter Passias, M.D., with the NYU Langone Orthopedic Hospital, explained the underlying rationale behind this new study to OTW, “In the past five years, I have seen a rapid growth in multilevel arthrodesis procedures using minimally invasive surgery techniques. Increasingly, we are tackling more challenging cases with these approaches, yet the technology and our techniques have not had a chance to completely evolve with our ambitions.”
“With this being an up-and-coming approach, I wanted to assess the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length relative to its initial single level applications.”
To understand the risks and benefits, the research team selected patients who were undergoing <4 level lumbar interbody fusion were stratified by surgical technique (MIS or open), and grouped by fusion length: 1-level, 2-levels, 3+ levels. They then collected demographic data, each patient’s Charlson Comorbidity Index (CCI), various surgical factors and perioperative complication rates and then compared the data for each of the technique groups at different fusion lengths using means comparison tests.
Dr. Passias summarized his results to OTW, “While MIS patients had lower rates of perioperative complications for 1- and 2- level fusions, 3+ level MIS fusions had comparable complication rates to open cases, and higher rates of adverse pulmonary and ileus events. Although that MIS patients sustained less intraoperative blood loss at all fusion lengths, at 3+ level fusions, MIS and open groups had similar rates of blood loss anemia.”
“As a whole, these results suggest that the key benefits of a minimally invasive surgical technique may be less advantageous for 3+ level lumbar interbody fusions, and there is a tendency towards the mean with open and MIS cases with regards to peri-operative outcomes.”
“Although on the surface, minimally invasive surgical techniques may aim to reduce risk to the patient, our study shows there may be a limitations and future development is needed. Surgeons should consider the parallel risk that 3+ MIS fusions and open procedures have on preoperative risk assessment.”
I had a very successful open anterior/posterior fusion of L5/S1. I had two minimally invasive surgeries on L3-5 for symptomatic adjacent segment pathology that had progressed to severe neurological deficits. I was given no options, coerced into a surgery without regard to my preferances. My 2 level microdiscectomy/decompression resulted in more pain, a hospitalization longer than for my first open 360 fusion, and I have permanent nerve damage. Then because of scar tissue was told an XLIF would be better to indirectly address retrolisthesis and severe foraminal stenosis. It did not improve the stenosis, and just added a new problem, long term GI issues and hernia. Now I can go for another decompression, but the liklihood of success is low, and after 18 mos of unrelenting pain, muscle spasms and difficulty walking, how much damage is permanent, I have no clue. And no, I do not take narcotics, and I am not obese, getting disability, etc. So all the normal discriminatory patient blame do not apply.
I preferred the most throrough procedure done at once, vs putting bandaids on failed procedures. I suffered far more from supposedly MIS procedures than an open procedure.
Spine surgeons get too caught up in gadgets and short term outcomes, and as soon as there is an issue, default to how they can blame the patient. Unless patient age/health/preferance is a determining factor, who thinks it is better to operate with less visibility?
For example, my XLIF, I have residual disc herniated, I thought the MRI reading was incorrectly calling the cages disc..but no, there is residual disc, as well as severe stenosis. I imagine an open decompression/fusion surgery addressing all symptomatic pathology the good old fashioned way would not have resulted in poor results.
Get in touch with the Deuk Spine Institute in Melbourne Florida and they will answer all your questions and possibly help you with your pain.
I think you’re right…i sometimes wonder if I would have needed the multiple minimally invasive ones I’ve been given ( and still need surgery again) if they’d just do an open one.
January 2019 I had spine surgery. L2 thru L5 are fused with hardware. I decided to go ahead with the surgery because years of physical therapy were no longer working. I needed a cane to walk. From the Xrays and MRI, my opinion was that it was either surgery or a wheel chair. It went well. I still do PT and am careful about body mechanics. But 2 years in, I am still very glad I had it done. Am I pain free? No. but the pain is occasional and manageable.
Fran, I would like to know how old you were when you had surgery and what was the recovery time? Considering same surgery.
Hey Fran, How old were you when you got your fusion? Did you have your L2, L3, L4 and L5 fused? I am 32years old and am an ex-NCAA D1 and World Team Wrestler, which played a substantial factor in my current pain and back issues. I have had 3 opinions and will be traveling to Seattle soon for a 4th. I have had one surgeon say they didnt know what to do, they were stumped. The 2nd said I would need a fusion at some point and then the 3rd said that I need a fusion for my L2-L3-L4-L5-S1. I am rather timid/scared because I hear alot of negatives and also alot of positives. Part of me wants to deal with it and continue with a poor quality of life and miserable pain while trying to manage on pain killers, and the other part just wants to do it in hopes that I can be one of the positive stories.
How long before you were able to get back to work?
Hello,
I am about to undergo L-2 through S-1. I have no choice…but would love to hear more about your recovery process and your mobility now.
Thank you-Jaynie
I’m considering 4 level fusion. Am wanting to hear any wisdom concerning this. I’m 67 I have 3 bulging disc’s, degeneration disc disease and spinal stenosis. I have been living with chronic back pain for over 30 yrs.
Wondering if this surgery will help me. I’m not able to walk or stand without severe pain.
Hi my name is Mark and I’m a 67-year-old man and I am in great health and in great shape with the exception of my L2 through L4 lumbar discs. I have been diagnosed with DDD coupled with arthritis. I am being told by medicare that because of my age disc replacement is not an option for me as it is not covered. I’ve been seeing an orthopedic surgeon who has instructed me that my next option is fusion of the L2 through L4 vertebrae. Has anybody had any experience with fusing the L2 through L4 vertebrae? If yes how active are you? Do you think I be able to play golf? Will I still be able to walk 5 miles three times a week? I know these questions are subjective based on a persons physical capabilities and surgical outcome but I am hoping that someone here has had some experience and may be able to answer some of these questions partially.
I’m 71 years old, very active, low weight. I had 3 level fusion L3-4, l4-5, and L5-S1, almost 8 years ago. I had a car accident 16 years ago and had nearly every injection, physical therapy, neurotomy, etc but finally my only option was surgery. I have the hardware still and have some pain but can do all activists and still ride upper level
Horses. I’m very happy with surgery. While I’m not a golfer, I’m sure that is more than possible. My surgery was done at USC.
I am 4 weeks from surgery of 3 level fusion of my lumbar vertebrae. I couldn’t walk as result of bone spurs n narrowing of the spine. I refused to have it done,, but it became clear that it was necessary. It is very painful and hopefully it’ll heal quickly. X-ray this week before final post op. From what I have read, it may take 3-6 months to heal. The doctor wasn’t going to do it, but once into surgery, no choice. It’s disruptive for a person living alone.
I am 75 years old have had pain levels 7 to 9 for a coiple of years. i had a radio frequency ablation. very little help. had 6 or 7 epidurals gives about 3 weeks relief each,. have spinel synopsis, some arthritis. have cartilage about gone in my knees, get a gel knee injection, every six months helps a little, about 30 pounds over weight, gosh i was told a level 2 fusion, might help my back, and the back, of my right leg.. can anybody my age, and my problems give me any ideas. thanks guys.
I am a 77 yr old woman who just had 5 level fusion ( L2-S1) 8 weeks ago. I will be wearing a large back brace for 4 more weeks. I had multiple issues with my back for years….spinal stenosis, retrolithasis, bulging disc etc. I had multiple epidurals, nerve blocks, 2 ablations both sides, and it was finally time to consider surgery. I researched several neurosurgeons and decided on driving 2 hours to get the best neurosurgeon!
I’’ve had both a TLIF on one day and2 days later a PLIF. Nearly 12 hours of anesthesia combined! The first week to 20 days I need total assistance for most things. Although, I was walking 🚶♀️ the hall with PT Later in the day. All my nerve pain in my back, hip and legs was gone!.
I was on pain meds 3-4x a day and anti spasm meds too.
After a few weeks the only real pain was muscle spasms on my left side from them separating my abdominal muscles and that also caused spasms in my left thigh. I still has muscle spasms but mostly in my back as I begin to be more active with household activity. Those muscles become weak after wearing a brace for 12 weeks.
My body tells me when I’ve over done it!
I went in the pool this past week and walked 10 laps. That night I had muscle spasms
In my thighs. Too much too soon.
Occasionally I will take a pain med if I have had more activity that day than usual.
If I am in the car for more than an hour I need a pain med too.
My back gets tired ( brace on) when I’m standing for 2 long preparing dinner. I rest in between or do prep work sitting at a table.
I’m a 65-year-old male. Had Bi-lateral ablations, yrs of pt, injections all with little success. Dealing with multi level stenosis, bulging disc’s, arthritis
I am 3 wks post op on a 4 level L2-S1 fusion.
28 staples removed last week. Nerve pain and pressure in both legs are gone. Tomorrow may be 1st day on just Tylenol only. I see neurosurgeon again at 4 wks post op. I’m up walking every hour as directed. So far, this is going very well.
4 yrs ago had 2 levels fused in cervical region.
Numbness in arm still gone. Very little pain in cervical level.
Regret I didn’t take better care of back when younger. Worked in oil fields, lifted heavy weights, motorcycle & car wrecks and having a ladder break just as I was getting onto roof getting back to ground way to fast!
I am very pleased with surgery performed at Riverside hospital in Columbus Ohio by Dr Greg Baultershot.