Eur Spine J. 2013 Aug;22(8):1731-40.

Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high grade facet joint osteoarthritis.

Archavlis E

Department of Neurosurgery, Klinikum Offenbach, Akademisches Lehrkrankenhaus der Universität Frankfurt;



Dr. E. Archavlis

Consultant Neurosurgeon

Sana Klinikum Offenbach

Neurochirurgische Klinik und Ambulanz

Akademisches Lehrkrankenhaus der Universität Frankfurt

Starkenburgring 66, 63069 Offenbach, Germany

Tel.: 0049 178 9160743

Fax: 0049 69 8405 3143



Purpose: The object of this study was to compare MIS with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high grade facet osteoarthritis (FJO)

Methods: From January 2009 to February 2010, forty nine patients with severe SDS and high grade FJO were treated using either MIS or open transforaminal lumbar interbody fusion (TLIF). Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short and long term outcomes were assessed according to the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for back and leg pain.

Results: Comparing MIS and open surgery, the MIS group had lesser blood loss (EBL), significantly lesser need for transfusion (p = 0,02), more rapid improvement of postoperative back pain in the first 6 weeks of follow up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0,841), VAS leg (p = 0,943) and back pain (p = 0,735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29% in the MIS group vs. 28% in the open group, p = 0,999).

Conclusion: MIS for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.



Minimal invasive surgery has become a major goal across surgical subspecialties. Issues as diverse as cost containment, wound aesthetics, minimal muscle trauma and decreased pain have all served as an impetus to refine these techniques. Technologic advances have helped make these procedures safe, viable options for a wide variety of pathologic conditions.

A basic principle of minimally invasive spine surgery (MIS) is to effectively treat pathology with minimal disturbance of normal anatomy (1). Some reports although; suggest that the limited exposure that results from these techniques can result in incomplete treatment of pathology with no clear-cut advantage over traditional techniques. The avoidance of complications is more challenging through limited surgical portals. Failure surgery and reoperation rates can increase, especially in the field of lumbar instrumentation. In spite of these challenges, the evolution of MIS has exceeded that of traditional spine procedures over the past 2 decades (1,2,3).

Several studies have reported the favorable outcomes of minimally invasive tranforaminal lumbar interbody fusion (TLIF)  accompanied by spinal instrumentation with percutaneous pedicle screw insertion and decompression in degenerative spondylolisthesis (2). The area of greatest controversy, however, is the handling of cases with degenerative spondylolisthesis with severe stenosis of the spinal canal (3). The presence of severe arthritic changes of the facets is characteristic in many of these patients. Some authors prefer to perform the open interbody fusion and instrumentation in cases of spondylolisthesis with severe stenosis and spondylarthrosis because MIS techniques could limit direct visualization of neural elements and pedicle screws relative to key anatomical structures and could increase the rate of complications and pedicle screw misplacement.

We hypothethesized that MIS is safe, feasible and produces better short and long-term results than the open surgery in cases of a complex spinal disorder such as degenerative spondylolisthetic patients with severe stenosis (SDS) and high grade facet joint osteoarthritis (FJO).

We compared the findings of a MIS group (24 patients) with a reference group who underwent open surgery (25 patients) in the same period and focused our interest particularly on short and long-term results, accuracy of pedicle screw insertion and incidence of complications.

fig1Figure 1. One of the most important requirements for minimally invasive surgery is adequate fluoroscopic control in order to place precisely the tubular retractor system.


As it turns out, our hypothesis was partially correct. Although all cases included in this study were demanding because of the high grade of stenosis and FJO, this, however, did not translate in increased blood loss or perioperative morbidity compared with open surgery. On the contrary, blood loss in the MIS group was significantly less than in the open group. On the other hand we observed a longer duration of surgery in the MIS group which was on average 30 minutes longer in comparison with the open group. Figure 1 shows the most important aspect to the success of minimally invasive spine surgery, namely the proper patient placement in order to achieve an adequate fluoroscopic imaging of bony elements. Figure 2 illustrates that, although minimally invasive surgery use smaller skin incision, the same adequate decompression and fusion must be achieved in order to have a good clinical outcome.


Figure 2. Decompression and fusion procedures in cases with severe stenosis and pseudospondylolisthesis due to facet joint osteoarthritis are more difficult using minimally invasive surgery. The use of the operative microscope provides the best visualization through the limited working place of the tubular retractor system.


The MIS procedure in these complex and surgically demanding cases was neither associated with an increased rate of complications nor a higher surgical revision rate compared with the open procedure (29% vs. 28%, p = 0,999). We suppose that the limited soft tissue disruption of the MIS procedure could have a positive influence on the wound healing process which may explain the absence of wound healing disturbance or infection in the MIS group. Figure 3 shows that the application of minimally invasive spinal surgery is important not only to minimize muscle trauma but also to limit the length of the skin incision.


Figure 3. All minimally invasive instrumentation steps are made though the limited surgical portals. Subcuticular resorbable sutures are used to close the wound, resulting in a desirable cosmetic result.


One of the main advantages of MIS was the rapid relief of postoperative back pain in the first 6 weeks postoperatively. Patients after MIS showed also a more rapid functional recovery in the same period in comparison to patients after open surgery. It is obvious that due to lessening of the approach related morbidity; minimally invasive techniques offer a quicker recovery. Figure 4 shows that patients operated under minimally invasive technique had less postoperative pain and were able to mobilize earlier, compared with open surgery. On the long term MIS achieves the same objectives as open surgery even in this complex and surgically demanding patient population and after 2 years there were no differences in outcome.


Figure 4. Change in Oswestry Disabilty Index (ODI) score at 6 weeks and 2 years postoperatively in the MIS and open group. There was a more rapid improvement during the first 6 weeks of follow up in the MIS group.

In summary, postoperative outcome in MIS was similar to traditional open surgery; however, patients who underwent MIS generally had less postoperative pain and were able to mobilize earlier in the early postoperative period, compared with open surgery. Although all of the complications of open surgery were still relevant in the MIS procedure, certain complications, such as infection and heavy bleeding, are less frequent with MIS procedures. The importance of this study is that it shows that the relative benefits of MIS are applicable even in cases of a complex spinal disorder such as degenerative spondylolisthetic patients with severe stenosis (SDS) and high grade facet joint osteoarthritis (FJO).



  1. Oppenheimer JH, De Castro I, McDonnell DE (2009) Minimally invasive spine technology and minimally invasive spine surgery: a historical review. Neurosurg Focus 27(3):E9
  2. Scheufler KM, Dohmen H, Vougioukas VI (2007) Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery 60(4 Suppl 2):203-12
  3. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J (2010) Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J 19(10):1780-4
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