Study design: Systematic review.
Objective: The purpose of this review was to attempt to answer the following 2 clinical questions: (1) Does minimal access tubular assisted spine surgery (MAS) decrease the rate of complications in posterior thoracolumbar decompression and/or fusion surgery compared with traditional open techniques? (2) What strategies to reduce the risk of complications in MAS have been shown to be effective?
Summary of background data: The objective of minimal access spine surgery is to reduce damage to surrounding tissues while accomplishing the same goals as conventional surgery. Patient demand and marketing for MAS is driven by the perception of better outcomes, although the purported advantages remain unproven. Whether the risk of complications is affected by minimal access techniques is unknown.
Methods: A systematic review of the English language literature was undertaken for articles published between 1990 and July 2009. Electronic databases and reference lists of key articles were searched to identify published studies that compared the rate of complications after MAS to a control group that underwent open surgery. Single-arm studies were excluded. Two independent reviewers assessed the strength of literature using GRADE criteria assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus.
Results: From the 361 articles identified, 13 met a priori criteria and were included for review. All of the studies evaluated only lumbar spine surgery. The single large randomized study showed less favorable results for MAS discectomy, but no significant difference in complication rates. The quality of the other studies, particularly for fusion surgery, was low. Overall, the rates of reoperation, dural tear, cerebrospinal fluid leak, nerve injury, and infection occurred in similar proportions between MAS and open surgery. Blood loss was reduced in MAS fusion; however, the quality of those studies was very low. Operation time and hospital length of stay was variable across studies. There was no evidence to assess the effectiveness of strategies to reduce the risk of complications in MAS. Some data suggests that the rate of complications may decrease with experience.
Conclusion: (1) Compared to open techniques, MAS does not decrease the rate of complications for posterior lumbar spinal decompression or fusion. (2) There is no evidence to assess the effectiveness of strategies to reduce the risk of MAS-related complications.