Comparison of hidden blood loss and clinical efficacy of percutaneous endoscopic transforaminal lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion


Hidden blood loss (HBL) is a growing area of interest for spinal surgeons. Simultaneously, spine surgeons’ pursuit of minimally invasive spine surgery has never ceased, as evidenced by the increasing number of articles comparing percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) and minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF). However, there has been no comparison of HBL between Endo-TLIF and Mis-TLIF. This study aimed to compare HBL, visible blood loss (VBL), and total blood loss (TBL) following Endo-TLIF and Mis-TLIF and evaluate the clinical significance of these procedures.


Between October 2017 and October 2019, 370 patients underwent lumbar interbody fusion at our institution and were followed up for at least 24 months. Our study included 41 Endo-TLIF and 43 Mis-TLIF cases. We recorded each patient’s age, height, weight, and haematocrit and calculated the TBL, which was used to indirectly obtain the HBL. Additionally, we compared the clinical outcomes of these two groups, including visual analogue scores for the lumbar spine and leg (VAS-Back; VAS-Leg), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, disease type, operative segment, and intervertebral fusion and complication rates.


Endo-TLIF had significantly lower HBL, VBL, and TBL values than Mis-TLIF (P < 0.05 for all). Although Endo-TLIF contained significantly less HBL than Mis-TLIF, the HBL to TBL ratio was statistically greater in Endo-TLIF (91%) than in Mis-TLIF (87%). Concerning clinical outcomes, VAS-Back, VAS-Leg, ODI, JOA, and Endo-TLIF demonstrated greater improvement rates than Mis-TLIF one week post-operatively. However, at the final follow-up, VAS-Back, VAS-Leg, ODI, and JOA scores all demonstrated a trend toward sustained improvement, with no statistically significant between-procedure difference. There were no statistically significant between-procedure differences in disease type, surgical segment, and complication or fusion rates.


Endo-TLIF significantly reduced HBL, VBL, and TBL compared to Mis-TLIF and improved short-term clinical outcomes; however, long-term clinical outcomes and fusion rates remained comparable between the two groups, as did the incidence of peri-operative complications.


Hidden blood loss; Minimally invasive transforaminal lumbar interbody fusion; Percutaneous endoscopic transforaminal lumbar interbody fusion; Total blood loss; Visual blood loss.

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