Precision risk stratification for perioperative safety of minimally invasive versus open TLIF in elderly patients with lumbar degenerative disease
Year: 2026
Type: article
Abstract: Lumbar degenerative disease is highly prevalent in elderly patients, and transforaminal lumbar interbody fusion (TLIF) is a standard surgical treatment. However, the comparative safety of minimally invasive (MIS-TLIF) versus open TLIF in this vulnerable population remains incompletely defined, particularly regarding effect modifiers and underlying mechanisms. This retrospective cohort study included 728 patients aged ≥ 60 years who underwent primary TLIF, with 1:1 propensity score matching (PSM) performed to balance baseline characteristics. Perioperative outcomes were compared, and 30-day complications were analyzed using the Fine-Gray competing risk model. Subgroup analysis, mediation analysis, and a gradient boosting machine learning predictive model were conducted to explore effect heterogeneity, mechanisms, and risk stratification. After PSM, all baseline variables were well balanced (all standardized mean differences < 0.05). The MIS-TLIF group exhibited significantly shorter operative time, less intraoperative blood loss, lower transfusion rates, faster postoperative recovery, and reduced 30-day and 90-day unplanned readmission rates (all P < 0.001). After adjusting for competing risks, MIS-TLIF was associated with a 52% lower risk of any 30-day complication (adjusted subdistribution hazard ratio [SHR] = 0.48, 95% CI 0.34–0.68, P < 0.001) and a 61% lower risk of major complications (adjusted SHR = 0.39, 95% CI 0.21–0.72, P = 0.003). Subgroup analysis revealed significant interactions between treatment effect and age (P for interaction = 0.007) and frailty index (P for interaction < 0.001), with exponentially greater benefits observed in patients aged ≥ 72 years and frail patients. Intraoperative blood loss and operative time mediated 41.3% and 18.9% of the total protective effect, respectively, with a total mediating effect of 60.2%. The predictive model achieved an area under the receiver operating characteristic curve of 0.83 in the validation set, and the relative risk reduction of complications with MIS-TLIF reached 78% in the very high-risk group. MIS-TLIF significantly improves perioperative safety in elderly patients with lumbar degenerative disease, with the greatest benefit in high-risk subgroups. The developed risk prediction model can facilitate personalized surgical decision-making for this population.
Source: Scientific Reports
Language: English
Subfield: Pathology and Forensic Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,690
OpenAlex ID: W7222865892
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