One center's experience with hybrid technique for lumbar spine instrumentated surgeries: evaluation of different instrumentation systems and their management

Background: Minimally invasive surgery (MIS) has been providing many solutions in spine surgery, and several technical variations and instrumentation systems are available. The aim of our study is to investigate the best system to perform a hybrid technique in lumbar spine fusion procedures. Methods: Sixteen patients were enrolled and randomly assigned to 1 of the 4 groups reported later. The first step in any case was midline incision, fascia exposure, and, using trocars, intravertebral transpedicle Kirschner wires (KWs) positioning through the fascia. Group definitions were A) KWs were affixed to surgical towels; B) screws with metal extensors were placed and KWs removed; C) screws with plastic extensors (K2M) were placed and those extensors were affixed to surgical towels; and D) screws without extensors or tulips (Nuvasive) were positioned. We locked the system at the end of procedure, after posterior decompression and translumbar interbody fusion cage placement. Procedures’ features were rated using properly designed questionnaires by surgeons. Results: Metal extensors were rated lower than other systems in any aspect. C and D groups’ procedures were higher rated than those in A and B in all examined fields. Furthermore, group D's procedures were reported more comfortable during facetectomy, diskectomy, and cage placement. Surgeons reported Precept Modular (Nuvasive) as the most comfortable and useful system in the hybrid technique. Conclusions: Precept Modular seems to be the most useful system when performing hybrid technique in lumbar fusion procedures. Furthermore, it results in the only one that provides the opportunity to easily and quickly switch from minimally invasive surgery to open surgery, avoiding muscles’ injuries.