Published date: Jul 22 2024

Journal Title: Journal of Spine Practice

Issue title: Journal of Spine Practice (JSP): Volume 3, Issue 2

Pages: 52–60

DOI: 10.18502/jsp.v3i2.14802

Alexandros Moniakis MD, MScmoniakis.alexandros@gmail.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Niels Pacheco-Barrios MScDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Esteban Quiceno MDequicenor@gmail.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Amna Hussein MDAmnaSaid.Hussein@bannerhealth.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Annie Pico MSapico@arizona.eduDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Ebtesam Abdulla MDdr.ebtesam.ua@gmail.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Isabel L. Bauer MSibauer@email.arizona.eduDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Kristin Nosova MDDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Monis Ahmed Khan MDkhanmon75@gmail.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Dara S. Farhadi MDdarafarhadi@email.arizona.eduDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Michael Prim MDMichael.Prim@bannerhealth.comDepartment of Neurosurgery, Banner University Medical Center, Phoenix, AZ

Ali Baaj MDAli.Baaj@bannerhealth.comDepartment of Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ

Objective: The advantages of minimally invasive spine surgery (MISS) in lumbar degenerative diseases have been well described (less tissue damage, shorter hospital stay, better results in pain assessment). One aspect that has not yet been studied enough is the usage of a post-operative drain in MISS. The aim of this study was to determine whether drainage in MISS is necessary or not and what advantages or disadvantages its use offers.

Materials - Methods: We conducted a systematic review of the published literature, searching articles published on Pubmed and Embasse until December 1st 2022, regarding MISS in the lumbar region and post-operative drain usage. Our inclusion criteria were original articles written in English and articles using minimally invasive techniques (usage of tubular retractors along with an endoscope or microscope, paramedian incision, percutaneous screw placement). 42 articles were assessed, and after careful examination and duplication exclusion, 26 research papers were included. Usage, type and duration of postoperative drainage, length of hospital stay, ambulation time and complications were extracted, and relevant results were pooled.

Results: The majority of the included articles (80.7 %) reported using a negative-pressure post-operative drain tube. Drains were removed either 48 hours after surgery or when the drainage volume was less than 50ml/24h. Hospital stays and time to ambulation were shorter in cases where drainage was not used. There was no difference in complications between cases where drainage was used and those that it was not.

Conclusion: The rationale behind post-operative drainage in MISS is to protect from surgical site infections and hematoma creation. Based on our study there is no evidence to support this hypothesis. On the contrary, our results suggest that the drawbacks of using a drain (pain, discomfort, anxiety, inconvenience of mobilisation, prolongation of hospitalisation) outweigh the advantages, thus making the routine use of postoperative drainage in MISS unnecessary.

Keywords: minimally invasive, spine surgery, drains, complications

[1] Ravindra VM, Senglaub SS, Rattani A, Dewan MC, Härtl R, Bisson E, et al. Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume. Global Spine J. 2018 Dec;8(8):784–94.

[2] Starkweather AR, Witek-Janusek L, Nockels RP, Peterson J, Mathews HL. The multiple benefits of minimally invasive spinal surgery: results comparing transforaminal lumbar interbody fusion and posterior lumbar fusion. J Neurosci Nurs. 2008 Feb;40(1):32–9.

[3] Phillips FM, Cheng I, Rampersaud YR, Akbarnia BA, Pimenta L, Rodgers WB, et al. Breaking Through the “Glass Ceiling” of Minimally Invasive Spine Surgery. Spine. 2016 Apr;41 Suppl 8:S39–43.

[4] Lener S, Wipplinger C, Hernandez RN, Hussain I, Kirnaz S, Navarro-Ramirez R, et al. Defining the MIS-TLIF: A Systematic Review of Techniques and Technologies Used by Surgeons Worldwide. Global Spine J. 2020 Apr;10(2 Suppl):151S–67S.

[5] Adogwa O, Elsamadicy AA, Sergesketter AR, Shammas RL, Vatsia S, Vuong VD, et al. Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma. J Spine Surg. 2018 Jun;4(2):220–6.

[6] von Eckardstein KL, Dohmes JE, Rohde V. Use of closed suction devices and other drains in spinal surgery: results of an online, Germany-wide questionnaire. Eur Spine J. 2016 Mar;25(3):708–15.

[7] Andrew Glennie R, Dea N, Street JT. Dressings and drains in posterior spine surgery and their effect on wound complications. J Clin Neurosci. 2015 Jul;22(7):1081–7.

[8] Kim CH, Easley K, Lee JS, Hong JY, Virk M, Hsieh PC, et al. Comparison of Minimally Invasive Versus Open Transforaminal Interbody Lumbar Fusion. Global Spine J. 2020 Apr;10(2 Suppl):143S–50S.

[9] Gao G, Cao L, Du X, Xu B, Zhang P, Zhang X, et al. Comparison of Minimally Invasive Surgery Transforaminal Lumbar Interbody Fusion and TLIF for Treatment of Lumbar Spine Stenosis. J Healthc Eng. 2022 Jan;2022:9389239.

[10] Tian W, Xu YF, Liu B, Liu YJ, He D, Yuan Q, et al. Computer-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion May Be Better Than Open Surgery for Treating Degenerative Lumbar Disease. Clin Spine Surg. 2017 Jul;30(6):237–42.

[11] Liu H, Li J, Sun Y, Wang X, Wang W, Guo L, et al. A Comparative Study of a New Retractor-Assisted WILTSE TLIF, MIS-TLIF, and Traditional PLIF for Treatment of Single-Level Lumbar Degenerative Diseases. Orthop Surg. 2022 Jul;14(7):1317–30.

[12] Du JP, Wang XH, Shan LQ, Wang WT, Li HK, Huang DG, et al. Safety and Efficacy of Minimally Invasive Transforaminal Lumbar Interbody Fusion Combined with Gelatin Sponge Impregnated with Dexamethasone and No Drainage Tube after Surgery in the Treatment of Lumbar Degenerative Disease. Orthop Surg. 2021 May;13(3):1077–85.

[13] Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265–70.

[14] Harakuni T, Iwai H, Oshima Y, Inoue H, Kitagawa T, Inanami H, et al. Full-Endoscopic Lumbar Interbody Fusion for Treating Lumbar Disc Degeneration Involving Disc Height Loss: technical Report. Medicina (Kaunas). 2020 Sep;56(9):478.

[15] Feng S, Tian W, Wei Y. Clinical Effects of Oblique Lateral Interbody Fusion by Conventional Open versus Percutaneous Robot-Assisted Minimally Invasive Pedicle Screw Placement in Elderly Patients. Orthop Surg. 2020 Feb;12(1):86–93.

[16] Kogias E, Klingler JH, Franco Jimenez P, Vasilikos I, Sircar R, Scholz C, et al. Incidental Durotomy in Open Versus Tubular Revision Microdiscectomy: A Retrospective Controlled Study on Incidence, Management, and Outcome. Clin Spine Surg. 2017 Dec;30(10):E1333–7.

[17] Cui GY, Han XG, Wei Y, Liu YJ, He D, Sun YQ, et al. Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis. Orthop Surg. 2021 Oct;13(7):1960–8.

[18] Gao G, Cao L, Du X, Xu B, Zhang P, Zhang X, et al. Comparison of Minimally Invasive Surgery Transforaminal Lumbar Interbody Fusion and TLIF for Treatment of Lumbar Spine Stenosis. J Healthc Eng. 2022 Jan;2022:9389239.

[19] Kang MS, You KH, Choi JY, Heo DH, Chung HJ, Park HJ. Minimally invasive transforaminal lumbar interbody fusion using the biportal endoscopic techniques versus microscopic tubular technique. Spine J. 2021 Dec;21(12):2066–77.

[20] Takami M, Yoshida M, Minamide A, Hashizume H, Yukawa Y, Nakagawa Y, et al. Does prophylactic use of topical gelatin-thrombin matrix sealant affect postoperative drainage volume and hematoma formation following microendoscopic spine surgery? A randomized controlled trial. Spine J. 2021 Mar;21(3):446–54.

[21] Tian W, Xu YF, Liu B, Liu YJ, He D, Yuan Q, et al. Computer-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion May Be Better Than Open Surgery for Treating Degenerative Lumbar Disease. Clin Spine Surg. 2017 Jul;30(6):237–42.

[22] Shi L, Ding T, Shi Y, Wang F, Wu C. Comparison of the Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion and Endoscopic Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Diseases: A Retrospective Matched Case-Control Study. World Neurosurg. 2022 Nov;167:e1231–40.

[23] Ao S, Zheng W, Wu J, Tang Y, Zhang C, Zhou Y, et al. Comparison of Preliminary clinical outcomes between percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases in a tertiary hospital: is percutaneous endoscopic procedure superior to MISTLIF? A prospective cohort study. Int J Surg. 2020 Apr;76:136–43.

[24] Kim JE, Yoo HS, Choi DJ, Park EJ, Jee SM. Comparison of Minimal Invasive Versus Biportal Endoscopic Transforaminal Lumbar Interbody Fusion for Single-level Lumbar Disease. Clin Spine Surg. 2021 Mar;34(2):E64–71.

[25] Senker W, Stefanits H, Gmeiner M, Trutschnig W, Weinfurter I, Gruber A. Does Obesity Affect Perioperative and Postoperative Morbidity and Complication Rates After Minimal Access Spinal Technologies in Surgery for Lumbar Degenerative Disc Disease. World Neurosurg. 2018 Mar;111:e374–85.

[26] Gong J, Huang Z, Liu H, Zhang C, Zheng W, Li C, et al. A Modified Endoscopic Transforaminal Lumbar Interbody Fusion Technique: Preliminary Clinical Results of 96 Cases. Front Surg. 2021 Oct;8:676847.

[27] Senker W, Meznik C, Avian A, Berghold A. Perioperative morbidity and complications in minimal access surgery techniques in obese patients with degenerative lumbar disease. Eur Spine J. 2011 Jul;20(7):1182–7.

[28] Jing Z, Li L, Song J. Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy for upper lumbar disc herniation: a retrospective comparative study. Am J Transl Res. 2021 Apr;13(4):3111–9.

[29] Liu H, Li J, Sun Y, Wang X, Wang W, Guo L, et al. A Comparative Study of a New Retractor-Assisted WILTSE TLIF, MIS-TLIF, and Traditional PLIF for Treatment of Single-Level Lumbar Degenerative Diseases. Orthop Surg. 2022 Jul;14(7):1317–30.

[30] Liu JB, Wu JL, Zuo R, Li CQ, Zhang C, Zhou Y. Does MISTLIF or TLIF result in better pedicle screw placement accuracy and clinical outcomes with navigation guidance? BMC Musculoskelet Disord. 2022 Feb;23(1):153.

[31] Huang X, Wang W, Chen G, Guan X, Zhou Y, Tang Y. Comparison of surgical invasiveness, hidden blood loss, and clinical outcome between unilateral biportal endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative disease: a retrospective cohort study. BMC Musculoskelet Disord. 2023 Apr;24(1):274.

[32] Gao QY, Wei FL, Li T, Zhu KL, Du MR, Heng W, et al. Oblique Lateral Interbody Fusion vs. Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spinal Stenosis: A Retrospective Cohort Study. Front Med (Lausanne). 2022 May;9:829426.

[33] Gu S, Li H, Wang D, Dai X, Liu C. Application and thinking of minimally invasive transforaminal lumbar interbody fusion in degenerative lumbar diseases. Ann Transl Med. 2022 Mar;10(6):272.

[34] Librianto D, Ipang F, Saleh I, Srie Utami W, Aprilya D, Nurhayati R, et al. (2022) Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up. Open Access Macedonian Journal of Medical Sciences. 2022;10(B):1188– 1194. https://doi.org/10.3889/oamjms.2022.9043..

[35] Kim HS, Wu PH, Jang IT. Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression Outside-In Approach: A Proctorship Guideline With 12 Steps of Effectiveness and Safety. Neurospine. 2020 Jul;17 Suppl 1:S99–109.

[36] Heo DH, Hong YH, Lee DC, Chung HJ, Park CK. Technique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion. Neurospine. 2020 Jul;17 Suppl 1:S129– 37.

[37] He EX, Cui JH, Yin ZX, Li C, Tang C, He YQ, et al. A minimally invasive posterior lumbar interbody fusion using percutaneous long arm pedicle screw system for degenerative lumbar disease. Int J Clin Exp Med. 2014 Nov;7(11):3964–73.