3.3 Postoperative recovery
All incisions displayed adequate healing in both groups, and no patient suffered from incision-related complications. No patient suffered from pulmonary infection or respiratory failure. In the NAV group, two patients had anterior numbness of the ipsilateral thigh, and five others felt weak when flexing the hip. In the non-NAV group, two patients had anterior numbness of ipsilateral thigh and 4 patients felt weak when flexing the hip. These patients received physiotherapy, acupuncture, and neurotrophic drugs, and recovered within 1 to 3 months of surgery. At the last follow-up, 12 patients had complete fusion, and 6 showed possible fusion in the NAV group. No patient had loose internal fixation. A total of 10 and 5 patients had complete and possible fusion in the non-NAV group, respectively. No patient had loose internal fixation.
Surgical treatment of spinal tuberculosis requires complete debridement, interbody fusion, and internal fixation; however, traditional open anterior approach surgery could result in more severe trauma and affect recovery in spine tuberculosis. Minimally invasive surgical treatments of spinal tuberculosis include CT, B-mode ultrasound-guided percutaneous drainage of local abscess, catheter drainage, thoracoscopy- or laparoscopic-assisted surgery, channel assisted minimally invasive anterior approach surgery, side approach, and posterior approach surgery.[21,22]
DLIF is a minimally invasive technique using a channel of the lumbar lateral approach, which passes from the extra-peritoneal psoas to the intervertebral space, in order to complete lesion clearance, intervertebral fusion, and orthopedics. This technique has the advantages of minimal trauma, mild postoperative pain, and fast recovery. It is mainly applied in lumbar degenerative diseases, intervertebral fusion, and scoliosis.[23,24] In recent years, this technique has been applied for minimally invasive surgery in lumbar tuberculosis, with satisfactory results. Nevertheless, as with other minimally invasive techniques for spinal surgery, due to the establishment of small channels, minimal incision, and limited view, the surgical process relies on repeated intraoperative C-arm fluoroscopy in order to ensure channel establishment and the accuracy of screw and cage implantation, avoiding nerve damage and achieving general surgical safety. Thus, this approach greatly increases radiation exposure in both the surgical staff and patients.[25,26] A previous study confirmed that radiation exposure during spinal surgery is far greater than in limb surgery. Mainly due to the different fat contents of soft tissues, clear imaging of the spine structure requires larger amounts of radiation than that of limbs. Similarly, larger amounts of radiation are required for obese patients during intraoperative fluoroscopy.
The spine structure is complex, and it is adjacent to important nerves and blood vessels. Moreover, spinal variation, deformity, and degeneration are common. Therefore, safety and accuracy in spinal surgery are hardly guaranteed. Since the application of computer navigation in the field of spine surgery, the precision of screw fixation has significantly improved, with reduced intraoperative radiation,[29–31] which improves the safety of minimally invasive spine surgery. Webb et al performed a cadaveric study and showed that channel establishment and disc removal times in the fluoroscopy group (19.6 ± 2.5 and 8.4 ± 2.0 min, respectively) are significantly greater than those of the navigation group (15.9 ± 4.1 and 6.0 ± 1.9 min, respectively). Nevertheless, preparation time in the navigation group was longer than that of the fluoroscopy group (5.8 ± 2.7 vs 3.0 ± 0.8 min) and total operation time showed no significant difference between the 2 groups. These findings suggested that computer navigation-assisted DILF surgery improves accuracy and reduces exposure to radiation. Moreover, operation time was not increased. The present study showed that intraoperative radiation exposure in the NAV group was significantly shorter than that of the non-NAV group, with no significant difference of total operation time between the 2 groups. Nevertheless, some authors claimed that the main disadvantages of computer navigation technology include increased operation time and surgical costs, alongside the long learning curve. Previous studies demonstrated that if the computer navigation technique is mastered proficiently, its application in the field of minimally invasive spinal surgery would not increase operation time.[32,34] In our clinical practice, although it takes some time for the preoperative installation of the reference frame and registration, the surgical preparation time could be significantly reduced if the operator is familiar with the computer navigation technology. Moreover, intraoperative repeated fluoroscopy was not required in the navigation group. Therefore, compared with the conventional fluoroscopy group, who were required to receive repeated anteroposterior and oblique fluoroscopy, time of channel establishment was significantly reduced in the navigation group. The results confirmed that total operation time in the navigation group was not longer than that of the non-navigation group, corroborating previous studies.[17,18,32,34] Despite the greater accuracy of navigation-assisted minimally invasive surgery, the present and previous studies failed to show improvements in success and outcomes.[17,18,32,34] Nevertheless, we consider that achieving improved radiological safety is a success in itself. The improved accuracy observed could possibly result in better long-term outcomes; however, since this technology is recent and has been used for a relatively short time, longer follow-up is necessary. The above findings suggested that the NAV approach is superior to the non-NAV method in minimally invasive DLIF for lumbar tuberculosis.
The present study had some limitations. First, the sample size was relatively small, and all patients were from a single center, therefore, larger sample, multicenter trials are required to validate the above findings. Second, computer navigation had the advantages of improving accuracy in spine surgery, but accuracy rates were not compared between the NAV and non-NAV groups. Finally, because of the retrospective nature of this study, we were limited to the data contained in medical charts. In particular, ESR and kidney and liver functions were not consistently available and could not be analyzed.
In conclusion, computer navigation-assisted minimally invasive DLIF could significantly reduce intraoperative radiation exposure, while not increasing total operation time. Additional studies are necessary to examine whether the improved accuracy also results in better long-term outcomes.
Conceptualization: Jianzhong Jiang, Fengping Gan.
Data curation: Jianzhong Jiang, Fengping Gan, Haitao Tan, Zhaolin Xie, Xiang Luo, Guoxiu Huang, Yin Li, Shengbin Huang.
Formal analysis: Jianzhong Jiang, Fengping Gan, Haitao Tan, Zhaolin Xie, Xiang Luo, Guoxiu Huang, Yin Li, Shengbin Huang.
Funding acquisition: Fengping Gan.
Project administration: Fengping Gan.
Writing – original draft: Jianzhong Jiang, Fengping Gan.
Writing – review & editing: Haitao Tan, Zhaolin Xie, Xiang Luo, Guoxiu Huang, Yin Li, Shengbin Huang.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
computer navigation; direct lateral interbody fusion; minimally invasive surgery; operation time; radiation exposure; spinal tuberculosis