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Xue S, Wu T. Biomechanical Performances of an Oblique Lateral Interbody Fusion Cage in Models with Different Bone Densities: A Finite Element Analysis. Indian J Orthop 2023; 57:86-95. [PMID: 36660489 PMCID: PMC9789258 DOI: 10.1007/s43465-022-00775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
Study Design Finite element models of the L3-S1 vertebrae were reconstructed using computed tomography scans. Objective We compared the biomechanical performances of an oblique lateral interbody fusion (OLIF) cage in different bone density mode. Summary of Background Data Low bone density is an els.key factor limiting the use of stand-alone OLIF cage. Methods Four models-intact (M0), normal bone density with OLIF (M1), bone mass loss with OLIF (M2), and osteoporotic with OLIF (M3)-were created based on 3-dimensional scans. Flexion, extension, and lateral bending movements (each lasting 10 N·m) were performed on the superior surface of the L3 vertebra with a compressive preload of 500 N. Range of motion (ROM), peak stresses in the L4-5 cortical endplates, cage stress, and adjacent intervertebral disk stress were evaluated. Results ROMs during different physiological movements were similar to those reported by previous researchers. Compared with that in M0, L4-5 ROMs of all movements decreased in M1, M2 and M3, most evidently in M3. Stress distribution in the cortical endplates rose to 7.8% in M1 and M2, even 16.2% in M3. Cage stress increased by less than 8.1% in M1 and M2, but by 25.3% in M3, especially in the movements of extension and right rotation. Compared with that in M0, L3-4 and L5-S1 intervertebral disk stress increased with bone density in all the other models, by up to 69.8% and 98.3%, respectively. As osteoporosis worsened, stress in the adjacent intervertebral disk also increased. Conclusion Stand-alone OLIF in M3 is not recommended because of the risk of cage subsidence. OLIF in M1 and M2 achieved similar results in various lumbar spine movements. In M1 and M2 model (T > - 2.5), the L4-L5 showed reduced mobility in all directions, increased rigidity, limited cage displacement, lessened deformation, and better stability.
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Affiliation(s)
- Shuangtao Xue
- Darpartment of Orthopaedics, The Second People’s Hospital of Wuhu, Wuhu Hospital Affiliated to East China Normal University, Wuhu, 241001 Anhui China
| | - Tianliang Wu
- Darpartment of Orthopaedics, The Second People’s Hospital of Wuhu, Wuhu Hospital Affiliated to East China Normal University, Wuhu, 241001 Anhui China
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Moser M, Adl Amini D, Jones C, Zhu J, Okano I, Oezel L, Chiapparelli E, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The predictive value of psoas and paraspinal muscle parameters measured on MRI for severe cage subsidence after standalone lateral lumbar interbody fusion. Spine J 2023; 23:42-53. [PMID: 35351664 DOI: 10.1016/j.spinee.2022.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT The effect of psoas and paraspinal muscle parameters on cage subsidence after minimally invasive techniques, such as standalone lateral lumbar interbody fusion (SA-LLIF), is unknown. PURPOSE This study aimed to determine whether the functional cross-sectional area (FCSA) of psoas and lumbar spine extensor muscles (multifidus and erector spinae), and psoas FCSA normalized to the vertebral body area (FCSA/VBA) differ among levels with severe cage subsidence after SA-LLIF when compared to levels without severe cage subsidence. STUDY DESIGN Retrospective single center cohort study. PATIENT SAMPLE Patients who underwent SA-LLIF between 2008 and 2020 for degenerative conditions using exclusively polyetheretherketone (PEEK) cages, had a lumbar magnetic resonance imaging (MRI) scan within 12 months, a lumbar computed tomography (CT) scan within 6 months prior to surgery, and a postoperative clinical and radiographic follow-up at a minimum of 6 months were included. OUTCOME MEASURES Severe cage subsidence. METHODS MRI measurements included psoas and combined multifidus and erector spinae (paraspinal) FCSA and FCSA/VBA at the L3-L5 pedicles. Following manual segmentation of muscles on axial T2-weighted images using ITK-SNAP (version 3.8.0), the FCSA was calculated using a custom written program on Matlab (version R2019a, The MathWorks, Inc.) that used an automated pixel intensity threshold method to differentiate between fat and muscle. Mean volumetric bone mineral density (vBMD) at L1/2 was measured by quantitative CT. The primary endpoint was severe cage subsidence per level according to the classification by Marchi et al. Multivariable logistic regression analysis was performed using generalized linear mixed models. All analyses were stratified by biological sex. RESULTS 95 patients (45.3% female) with a total of 188 operated levels were included in the analysis. The patient population was 92.6% Caucasian with a median age at surgery of 65 years. Overall subsidence (Grades 0-III) was 49.5% (53/107 levels) in men versus 58.0% (47/81 levels) in women (p=.302), and severe subsidence (Grades II-III) was 22.4% (24/107 levels) in men versus 25.9% (21/81 levels) in women (p=.608). In men, median psoas FCSA and psoas FCSA/VBA at L3 and L4 were significantly greater in the severe subsidence group when compared to the non-severe subsidence group. No such difference was observed in women. Paraspinal muscle parameters did not differ significantly between non-severe and severe subsidence groups for both sexes. In the multivariable logistic regression analysis with adjustments for vBMD and cage length, psoas FCSA at L3 (OR 1.002; p=.020) and psoas FCSA/VBA at L3 (OR 8.655; p=.029) and L4 (OR 4.273; p=.043) were found to be independent risk factors for severe cage subsidence in men. CONCLUSIONS Our study demonstrated that greater psoas FCSA at L3 and psoas FCSA/VBA at L3 and L4 were independent risk factors for severe cage subsidence in men after SA-LLIF with PEEK cages. The higher compressive forces the psoas exerts on lumbar segments as a potential stabilizer might explain these findings. Additional pedicle screw fixation might be warranted in these patients to avoid severe cage subsidence.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Conor Jones
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA.
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Cho SS, Farber SH, Kiernan H, Teng CW, Wanebo OR, Ponce FA, Tumialán LM, Wanebo JE. Management of hangman's fractures using anchored anterior cervical cages. Surg Neurol Int 2023; 14:125. [PMID: 37151433 PMCID: PMC10159285 DOI: 10.25259/sni_796_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/21/2023] [Indexed: 05/09/2023] Open
Abstract
Background Hangman's fractures comprise approximately 20% of C2 fractures and often require surgery to correct significant angulation and/or subluxation. Recently, anchored anterior cervical cages (ACCs) have been used to fuse C2-3 as they reduce the risks of soft-tissue dissection, bone drilling, operative time, and postoperative dysphagia. Methods This single-center and retrospective study (2012-2019) included 12 patients (3 type I, 6 type II, and 3 type IIa fractures) undergoing C2-3 ACCs (zero profile, half plate, full plate). Preoperative and postoperative radiographic and clinical data were analyzed. Results The 12 patients demonstrated the following findings: a mean operative time of 106 ± 21 min, blood loss averaging 67 ± 58 mL, and mean length of stay of 9.8 ± 7.7 days (6.4 ± 5.5 days in intensive care). The mean differences in preoperative versus postoperative radiographs showed an increase in disc angle (9.0° ± 9.4° vs. 14.0° ± 7.2°), reduction of subluxation (18.5% ± 13.6% vs. 2.6% ± 6.2%), and maintenance of C2-7 lordosis (14.3° ± 9.5° vs. 14.4° ± 9.5°). All patients demonstrated fusion on dynamic films obtained >6 months postoperatively. In addition, only one patient had Grade 0 subsidence, three had transient postoperative dysphagia, whereas none had either intraoperative complications or 90-day readmissions. Conclusion ACCs proved to be a viable alternative to traditional anterior cervical discectomy/fusion to treat 12 patients with C2-3 hangman's fractures in this preliminary study.
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Affiliation(s)
- Steve S. Cho
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - S. Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Hayley Kiernan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Clare W. Teng
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | - Oliver R. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Francisco A. Ponce
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Luis M. Tumialán
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
- Corresponding author: John E. Wanebo, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States.
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Wu J, Ao J, Xu Z, Li G, Ge T, Wang Y, Tao X, Tian W, Sun Y. Comparisons of oblique lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative spondylolisthesis: a prospective cohort study with a 2-year follow-up. Front Surg 2023; 10:1115823. [PMID: 37181603 PMCID: PMC10172686 DOI: 10.3389/fsurg.2023.1115823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Objective This study aimed to compare the clinical outcomes between oblique (OLIF) and transforaminal lumbar interbody fusion (TLIF) for patients with degenerative spondylolisthesis during a 2-year follow-up. Methods Patients with symptomatic degenerative spondylolisthesis who underwent OLIF (OLIF group) or TLIF (TLIF group) were prospectively enrolled in the authors' hospital and followed up for 2 years. The primary outcomes were treatment effects [changes in visual analog score (VAS) and Oswestry disability index (ODI) from baseline] at 2 years after surgery; these were compared between two groups. Patient characteristics, radiographic parameters, fusion status, and complication rates were also compared. Results In total, 45 patients were eligible for the OLIF group and 47 patients for the TLIF group. The rates of follow-up were 89% and 87% at 2 years, respectively. The comparisons of primary outcomes demonstrated no different changes in VAS-leg (OLIF, 3.4 vs. TLIF, 2.7), VAS-back (OLIF, 2.5 vs. TLIF, 2.1), and ODI (OLIF, 26.8 vs. TLIF, 30). The fusion rates were 86.1% in the TLIF group and 92.5% in the OLIF group at 2 years (P = 0.365). The OLIF group had less estimated blood loss (median, 200 ml) than the TLIF group (median, 300 ml) (P < 0.001). Greater restoration of disc height was obtained by OLIF (mean, 4.6 mm) than the TLIF group (mean, 1.3 mm) in the early postoperative period (P < 0.001). The subsidence rate was lower in the OLIF group than that in the TLIF group (17.5% vs. 38.9%, P = 0.037). The rates of total problematic complications were not different between the two groups (OLIF, 14.6% vs. TLIF, 26.2%, P = 0.192). Conclusion OLIF did not show better clinical outcomes than TLIF for degenerative spondylolisthesis, except for lesser blood loss, greater disc height restoration, and lower subsidence rate.
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Zhang Y, Liu C, Ge X. Clinical and radiographic outcomes of stand-alone oblique lateral interbody fusion in the treatment of adult degenerative scoliosis: a retrospective observational study. BMC Musculoskelet Disord 2022; 23:1133. [PMID: 36575399 PMCID: PMC9793660 DOI: 10.1186/s12891-022-06035-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 11/28/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Open fusion and posterior instrumentation has traditionally been the treatment for adult degenerative scoliosis (ADS). However, minimally invasive treatment such as oblique lateral interbody fusion (OLIF) technique was developed as a new therapeutic method for the treatment of ADS. In addition, it is associated with decreased blood loss and shorter operative time without posterior instrument. The purpose of this study was to evaluate the efficiency of stand-alone OLIF for the treatment of ADS in terms of clinical and radiological results. METHODS A total of 30 patients diagnosed with ADS who underwent stand-alone OLIF in our hospital from July 2017 to September 2018 were enrolled in the study. Scores from the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) obtained preoperatively and at the final follow-up were compared. Radiography and computed tomography were performed preoperatively and at the final follow-up. The coronal cobb angle, lumbar lordosis, disc height, sacral slope, pelvic incidence and Pelvic tilt were recorded at each time point. RESULTS The study cohort comprised 30 patients with a mean age of 64.5 ± 10.8 years and mean follow-up of 19.3 ± 4.2 months. The mean operative time was 96.8 ± 29.4 minutes and the mean estimated blood loss volume was 48.7 ± 9.4 ml. The mean coronal Cobb angle was corrected from 15.0° ± 3.7° preoperatively to 7.2° ± 3.1° postoperatively and 7.2° ± 3.3° at final follow-up (P < 0.0001). Lumbar lordosis significantly improved from 32.2° ± 11.3° preoperatively to 40.3° ± 11.8° postoperatively and 40.7° ± 11.0° at final follow-up (P < 0.01). The respective mean sacral slope and pelvic tilt improved from 26.1° ± 8.1° and 25.1° ± 6.9° preoperatively to 34.3° ± 7.4° and 19.2° ± 5.7° at final follow-up (P < 0.001). The mean disc height (defined as the mean of the anterior and posterior intervertebral disc heights) increased from 0.7 ± 0.3 cm preoperatively to 1.1 ± 0.2 cm at final follow-up (P < 0.0001). The interbody fusion rate on CT was 93.3%. The mean VAS pain score improved from 5.3 ± 0.6 before surgery to 2.3 ± 0.6 at final follow-up (P < 0.001). The mean ODI improved from 29.9% ± 6.8% preoperatively to 12.8% ± 2.4% at final follow-up (P < 0.001). CONCLUSIONS Stand-alone OLIF is an effective and safe option for treating ADS in carefully selected patients. TRIAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052419).
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Affiliation(s)
- Yu Zhang
- grid.27255.370000 0004 1761 1174School of Medicine, Shandong University, No. 44 Cultural West Road, Lixia District, Jinan City, 250012 Shandong Province China ,grid.27255.370000 0004 1761 1174Anhui Provincial Hospital, Shandong University, Hefei, 230001 Anhui China ,grid.443626.10000 0004 1798 4069Spine Research Center of Wannan Medical College, No.22 Wenchang West Road, Wuhu, 241001 Anhui China ,grid.452929.10000 0004 8513 0241Department of Spine Surgery, First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Wuhu, 241001 Anhui China
| | - Chen Liu
- grid.443626.10000 0004 1798 4069Spine Research Center of Wannan Medical College, No.22 Wenchang West Road, Wuhu, 241001 Anhui China ,grid.452929.10000 0004 8513 0241Department of Spine Surgery, First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Wuhu, 241001 Anhui China
| | - Xin Ge
- Department of Spine Surgery, Anqing first people’s Hospital, No. 187 Huazhong Road, Anqing, 241001 Anhui China
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Lang Z, Ge T, Wu J, Yuan Q, Sun Y. Comparison of transfacet and pedicle screws in oblique lateral interbody fusion for single-level degenerative lumbar spine diseases: a retrospective propensity score-matched analysis. BMC Surg 2022; 22:429. [PMID: 36522754 PMCID: PMC9753392 DOI: 10.1186/s12893-022-01880-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To perform a comparative assessment of percutaneous transfacet screws (TFS) and percutaneous bilateral pedicle screws (BPS) in oblique lateral interbody fusion (OLIF) for the treatment of single-level degenerative lumbar spine diseases in terms of radiological examinations and clinical outcomes. METHODS Sixty-six patients who received single-level OLIF with percutaneous supplementary fixation assisted by the robot for the treatment of degenerative lumbar spine diseases were selected. There were 16 cases of OLIF with TFS and 50 cases of OLIF with BPS. The propensity score matching method selected 11 patients in each group with matched characteristics to perform a clinical comparison. RESULTS The estimated blood loss was 68.2 ± 25.2 ml in the OLIF with TFS group compared to 113.6 ± 39.3 ml in the OLIF with BPS group (P < 0.05). The intervertebral disc height raised from 8.6 to 12.9 mm in the TFS group and from 8.9 to 13.9 mm in the BPS group in the immediate postoperative period, and dropped to 10.8 and 12.9 mm at the twelfth month, respectively (P < 0.05). The fusion rates were 91% and 100% for TFS and BPS groups (P > 0.05). Quantitative assessments of back/leg pain of the two groups reached a healthy level in the late period of the follow-up. CONCLUSION Both TFS and BPS techniques for the OLIF surgery relieve back pain caused by degenerative lumbar spine diseases. The TFS technique exhibits less blood loss compared with the BPS. A moderate cage subsidence is present in TFS but no complication is reported.
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Affiliation(s)
- Zhao Lang
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Tenghui Ge
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Jingye Wu
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Qiang Yuan
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Yuqing Sun
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
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Qiu MG, Zhou SG, Lin SS, Hu X, Lin C, Lin KF. Early effect of standalone oblique lateral interbody fusion vs. combined with lateral screw fixation of the vertebral body on single-level lumbar degenerative disc disease: A pilot study. J Back Musculoskelet Rehabil 2022; 36:709-719. [PMID: 36565101 DOI: 10.3233/bmr-220156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For the treatment of single-level lumbar degenerative disc disease (DDD), oblique lateral interbody fusion (OLIF) has clinical advantages. Whether internal fixation needs to be combined for treatment has been the subject of debate. OBJECTIVE To compare the early clinical effects of standalone oblique lateral interbody fusion (S-OLIF) versus OLIF combined with lateral screw fixation of the vertebral body (F-OLIF) on single-level lumbar DDD. METHODS A retrospective analysis was performed on the data of 34 patients for whom the OLIF technique was applied to treat single-level lumbar DDD from August 2018 to May 2021. Patients were divided into the S-OLIF (n= 18) and F-OLIF groups (n= 16). Intraoperative blood loss, operative time, and length of hospital stay were recorded. The pain visual analogue scale (VAS) and Oswestry disability index (ODI) before and after the operation were evaluated. The disc height (DH), foraminal height (FH), fused segment lordosis (FSL), lumbar lordosis (LL), cage subsidence, and fusion by CT examination were measured before and after the operation. RESULTS The S-OLIF group experienced a shorter operative time and less intraoperative blood loss than the F-OLIF group, and the differences were statistically significant (p< 0.05), but the difference in the length of hospital stay was not statistically significant. The postoperative VAS score and ODI of the two groups were significantly lower than those before the operation, but the postoperative differences between the two groups were not statistically significant. Differences were not statistically significant in postoperative FH, DH, FSL and LL of the two groups. Both groups were followed up for no less than 12 months. In the two groups, fusion was achieved at the last follow-up visit. CONCLUSION According to short-term follow-up results, both S-OLIF and F-OLIF can achieve reliable and stable fusion and good clinical effect in the treatment of single-level lumbar DDD.
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Affiliation(s)
- Mei-Guang Qiu
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Shi-Guo Zhou
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Shi-Shui Lin
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Xu Hu
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Cheng Lin
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Ke-Feng Lin
- Department of Orthopedics, Fujian Provincial Hospital South Branch, Fuzhou, Fujian, China.,Provincial Clinical College of Fujian Medical University, Fuzhou, Fujian, China
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Weng Y, Di M, Wu T, Ma X, Yang Q, Lu WW. Endplate volumetric bone mineral density biomechanically matched interbody cage. Front Bioeng Biotechnol 2022; 10:1075574. [PMID: 36561040 PMCID: PMC9763577 DOI: 10.3389/fbioe.2022.1075574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Disc degenerative problems affect the aging population, globally, and interbody fusion is a crucial surgical treatment. The interbody cage is the critical implant in interbody fusion surgery; however, its subsidence risk becomes a remarkable clinical complication. Cage subsidence is caused due to a mismatch of material properties between the bone and implant, specifically, the higher elastic modulus of the cage relative to that of the spinal segments, inducing subsidence. Our recent observation has demonstrated that endplate volumetric bone mineral density (EP-vBMD) measured through the greatest cortex-occupied 1.25-mm height region of interest, using automatic phantomless quantitative computed tomography scanning, could be an independent cage subsidence predictor and a tool for cage selection instruction. Porous design on the metallic cage is a trend in interbody fusion devices as it provides a solution to the subsidence problem. Moreover, the superior osseointegration effect of the metallic cage, like the titanium alloy cage, is retained. Patient-specific customization of porous metallic cages based on the greatest subsidence-related EP-vBMD may be a good modification for the cage design as it can achieve biomechanical matching with the contacting bone tissue. We proposed a novel perspective on porous metallic cages by customizing the elastic modulus of porous metallic cages by modifying its porosity according to endplate elastic modulus calculated from EP-vBMD. A three-grade porosity customization strategy was introduced, and direct porosity-modulus customization was also available depending on the patient's or doctor's discretion.
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Affiliation(s)
- Yuanzhi Weng
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Mingyuan Di
- Graduate School, Tianjin Medical University, Tianjin, China,Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Tianchi Wu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xinlong Ma
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
| | - Weijia William Lu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China,Research Center for Human Tissue and Organs Degeneration, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
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Kim SM, Kim YC, Kim KT, Ha KY, Luo Q, Li X, Park J. Surgical sequence in anterior column realignment with posterior osteotomy is important for degree of adult spinal deformity correction: advantages and indications for posterior to anterior sequence. BMC Musculoskelet Disord 2022; 23:1004. [PMID: 36419151 PMCID: PMC9682648 DOI: 10.1186/s12891-022-05915-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/28/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We hypothesized that posterior osteotomy prior to ACR (Anterior column realignment) through P-A-P surgical sequence would permit a greater correction for deformity corrective surgery than the traditional A-P sequence without posterior osteotomy. This study aimed to determine the impact of the P-A-P sequence on the restoration of lumbar lordosis (LL) compared to the A-P sequence in deformity corrective surgery for adult spinal deformity (ASD) patients and to identify the characteristics of patients who require this sequence. METHODS: Between 2017 and 2019, 260 ASD patients who had undergone combined corrective surgery were reviewed retrospectively. This study included 178 patients who underwent posterior osteotomy before the ACR (P-A group) and 82 patients who underwent the A-P sequence (A-P group). Sagittal spinopelvic parameters were determined from pre- and postoperative whole-spine radiographs and compared between the groups. To find better indications for the P-A-P sequence, we conducted additional analysis on postoperative outcomes of patients in the A-P group. RESULTS: The P-A group showed a significantly higher change in LL (53.7° vs. 44.3°, p < 0.001), C7 sagittal vertical axis (C7 SVA: 197.4 mm vs. 146.1 mm, p = 0.021), segmental lordosis (SL) L2/3 (16.2° vs. 14.4°, p = 0.043), SL L3/4 (16.2° vs. 13.8°, p = 0.004), and SL L4/5 (15.1° vs. 11.3°, p = 0.001) compared to the A-P group. At the final follow-up, pelvic incidence (PI) minus LL mismatch (PI - LL mismatch) was significantly higher in the A-P group (13.4° vs. 2.9°, p < 0.001). Stepwise logistic regression analysis showed that age ≥ 75 years (odds ratio [OR] = 2.151; 95% confidence interval [CI], 1.414-3.272; p < 0.001), severe osteoporosis (OR = 2.824; 95% CI, 1.481-5.381; p = 0.002), rigid lumbar curve with dynamic changes in LL < 10° (OR = 5.150; 95% CI, 2.296-11.548; p < 0.001), and severe facet joint osteoarthritis (OR = 4.513; 95% CI, 1.958-10.402; p < 0.001) were independent risk factors for PI - LL mismatch ≥ 10° after A-P surgery. CONCLUSION P-A-P sequence for deformity corrective surgery in ASD offers greater LL correction than the A-P sequence. Indications for the procedure include patients aged ≥ 75 years, severe osteoporosis, rigid lumbar curve with dynamic change in LL < 10°, or more than four facet joints of Pathria grade 3 in the lumbar region.
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Affiliation(s)
- Sung-Min Kim
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea
| | - Yong-Chan Kim
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea
| | - Ki-Tack Kim
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea
| | - Kee-Yong Ha
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea
| | - Qiang Luo
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea ,grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, Graduate School of Medicine, Kyung Hee University, Kyungheedae-ro, Dongdaemun-gu, Seoul, Korea
| | - Xiongjie Li
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea ,grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, Graduate School of Medicine, Kyung Hee University, Kyungheedae-ro, Dongdaemun-gu, Seoul, Korea
| | - JunBum Park
- grid.289247.20000 0001 2171 7818Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278 Seoul, Korea
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Malone H, Mundis GM, Collier M, Kidwell RL, Rios F, Jelousi M, Galli S, Shahidi B, Akbarnia BA, Eastlack RK. Can a bioactive interbody device reduce the cost burden of achieving lateral lumbar fusion? J Neurosurg Spine 2022; 37:646-653. [PMID: 36303478 DOI: 10.3171/2022.4.spine211070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intervertebral devices are increasingly utilized for fusion in the lumbar spine, along with a variety of bone graft materials. These various grafting materials often have substantial cost burdens for the surgical procedure, although they are necessary to overcome the limitations in healing capacity for many traditional interbody devices. The use of bioactive interbody fusion devices, which have demonstrable stimulatory capacity for the surrounding osteoblasts and osteoprogenitor cells and allow for osseointegration, may reduce this heavy reliance on osteobiologics for achieving interbody fusion. The objective of this study was to evaluate the rate of successful interbody fusion with a bioactive lateral lumbar interbody titanium implant with limited volume and low-cost graft material. METHODS The authors conducted a retrospective study (May 2017 to October 2018) of consecutively performed lateral lumbar interbody fusions with a bioactive 3D-printed porous titanium interbody device. Each interbody device was filled with 2-3 cm3/cage of a commercially available ceramic bone extender (β-tricalcium phosphate-hydroxyapatite) and combined with posterior pedicle screw fixation. No other biological agents or grafts were utilized. Demographic, clinical, and radiographic variables were captured. Fusion success was the primary endpoint of the study, with graft subsidence, fixation failure, and patient-reported outcomes (Oswestry Disability Index [ODI] and visual analog scale [VAS]-back and -leg pain scores) collected as secondary endpoints. The authors utilized a CT-based fusion classification system that accounted for both intervertebral through-growth (bone bridging) and ingrowth (integration of bone at the endplate-implant interface). RESULTS In total, 136 lumbar levels were treated in 90 patients. The mean age was 69 years, and 63% of the included patients were female. Half (50.0%) had undergone previous spinal surgery, and a third (33.7%) had undergone prior lumbar fusion. A third (33.7%) were treated at multiple levels (mean levels per patient 1.51). One year after surgery, the mean improvements in patient-reported outcomes (vs preoperative scores) were -17.8 for ODI (p < 0.0001), -3.1 for VAS-back pain (p < 0.0001), and -2.9 for VAS-leg pain (p < 0.0001). Bone bridging and/or appositional integrity was achieved in 99.3% of patients, including 97.8% who had complete bone bridging. No fixation loosening or implant failure was observed at any segment. Low-grade graft subsidence (Marchi grade ≤ I) occurred in 3 levels (2.2%), and intraoperative endplate violation occurred twice (1.5%). High-grade subsidence was not found. No implant failure or revision surgery for pseudarthrosis/subsidence was necessary. CONCLUSIONS The use of bioactive titanium interbody devices with a large surface footprint appears to result in a very high rate of effective fusion, despite the use of a small volume of low-cost biological material. This potential change in the osteobiologics required to achieve high fusion rates may have a substantially beneficial impact on the economic burden inherent to spinal fusion.
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Affiliation(s)
- Hani Malone
- 1Department of Neurosurgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Gregory M Mundis
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Martin Collier
- 3Department of Orthopedic Surgery, Naval Medical Center, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Reilly L Kidwell
- 1Department of Neurosurgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Fernando Rios
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Michael Jelousi
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Shae Galli
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Bahar Shahidi
- 4Department of Orthopedic Surgery, University of California, San Diego; and
- 5San Diego Spine Foundation, San Diego, California
| | | | - Robert K Eastlack
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
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Salmons HI, Baird MD, Dearden ME, Wagner SC, Sebastian AS. Prone Versus Lateral Decubitus Positioning for Direct Lateral Interbody Fusion. Clin Spine Surg 2022; 35:351-353. [PMID: 34966037 DOI: 10.1097/bsd.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/01/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | - Michael D Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Marissa E Dearden
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott C Wagner
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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Tani Y, Saito T, Taniguchi S, Ishihara M, Paku M, Adachi T, Ando M. Radiographic and MRI evidence of indirect neural decompression after the anterior column realignment procedure for adult spinal deformity. J Neurosurg Spine 2022; 37:703-712. [PMID: 35594889 DOI: 10.3171/2022.4.spine211432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anterior column realignment (ACR) procedure, which consists of sectioning the anterior longitudinal ligament/annulus and placing a hyperlordotic interbody cage, has emerged as a minimally invasive surgery (MIS) for achieving aggressive segmental lordosis enhancement to address adult spinal deformity (ASD). Although accumulated evidence has revealed indirect neural decompression after lateral lumbar interbody fusion (LLIF), whether ACR serves equally well for neural decompression remains to be proven. The current study intended to clarify this ambiguous issue. METHODS A series of 36 ASD patients with spinopelvic mismatch, defined as pelvic incidence (PI) minus lumbar lordosis (LL) > 10°, underwent a combination of ACR, LLIF, and percutaneous pedicle screw (PPS) fixation. This "MIS triad" procedure was applied over short segments with mean fusion length of 3.3 levels, and most patients underwent single-level ACR. The authors analyzed full-length standing radiographs, CT and MRI scans, and Oswestry Disability Index (ODI) scores in patients with minimum 1 year of follow-up (mean [range] 20.3 [12-39] months). RESULTS Compared with the preoperative values, the radiographic and MRI measurements of the latest postoperative studies changed as follows. Segmental disc angle more than quadrupled at the ACR level and LL nearly doubled. MRI examinations at the ACR level revealed a significant (p < 0.0001) increase in the area of the dural sac that was accompanied by significant (p < 0.0001) decreases in area and thickness of the ligamentum flavum and in thickness of the disc bulge. The corresponding CT scans demonstrated significant (all p < 0.0001) increases in disc height to 280% of the preoperative value at the anterior edge, 224% at the middle edge, and 209% at the posterior edge, as well as in pedicle-to-pedicle distance to 122%. Mean ODI significantly (p < 0.0001) decreased from 46.3 to 26.0. CONCLUSIONS The CT-based data showing vertebral column lengthening across the entire ACR segment with an increasingly greater degree anteriorly suggest that the corrective action of ACR relies on a lever mechanism, with the intact facet joints acting as the fulcrum. Whole-segment spine lengthening at the ACR level reduced the disc bulge anteriorly and the ligamentum flavum posteriorly, with eventual enlargement of the dural sac. ACR plays an important role in not only LL restoration but also stenotic spinal canal enlargement for ASD surgery.
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Alan N, Vodovotz L, Muthiah N, Deng H, Guha D, Agarwal N, Ozpinar A, Mushlin HM, Puccio L, Hamilton DK, Okonkwo DO, Kanter AS. Subsidence after lateral lumbar interbody fusion using a 3D-printed porous titanium interbody cage: single-institution case series. J Neurosurg Spine 2022; 37:663-669. [PMID: 35594892 DOI: 10.3171/2022.4.spine2245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cage subsidence is a well-known phenomenon after lateral lumbar interbody fusion (LLIF), occurring in 10%-20% of cases. A 3D-printed porous titanium (pTi) cage has a stiffness that mimics the modulus of elasticity of native vertebrae, which reduces stress at the bone-hardware interface, lowering the risk of subsidence. In this study, the authors evaluated their institutional rate of subsidence and resultant reoperation in patients who underwent LLIF using a 3D-printed pTi interbody cage. METHODS This is a retrospective case series of consecutive adult patients who underwent LLIF using pTi cages from 2018 to 2020. Demographic and clinical characteristics including age, sex, bone mineral density, smoking status, diabetes, steroid use, number of fusion levels, posterior instrumentation, and graft size were collected. The Marchi subsidence grade was determined at the time of last follow-up. Outcome measures of interest were subsidence and resultant reoperation. Univariable logistic regression analysis was performed to assess the extent to which clinical and operative characteristics were associated with Marchi grade I-III subsidence. Significance was assessed at p < 0.05. RESULTS Fifty-five patients (38 with degenerative disc disease and 17 with adult spinal deformity) were treated with 97 pTi interbody cages with a mean follow-up of 18 months. The mean age was 63.6 ± 10.1 years, 60% of patients were female, and 36% of patients had osteopenia or osteoporosis. Patients most commonly underwent single-level LLIF (58.2%). Sixteen patients (29.1%) had posterior instrumentation. The subsidence grade distribution was as follows: 89 (92%) grade 0, 5 (5%) grade I, 2 (2%) grade II, and 1 (1%) grade III. No patients who were active or prior smokers and no patients with posterior instrumentation experienced graft subsidence. No clinical or operative characteristics were significantly associated with graft subsidence. One patient (1.8%) required reoperation because of subsidence. CONCLUSIONS In this institutional case series, subsidence of pTi intervertebral cages after LLIF occurred in 8% of operated levels, 3% of which were grade II or III. Only 1 patient required reoperation. These reported rates are lower than those reported for polyetheretherketone implants. Further studies are necessary to compare the impact of these cage materials on subsidence after LLIF.
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Affiliation(s)
- Nima Alan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Lena Vodovotz
- 2University of Pittsburgh Medical Center, School of Medicine, Pittsburgh, Pennsylvania
| | - Nallammai Muthiah
- 2University of Pittsburgh Medical Center, School of Medicine, Pittsburgh, Pennsylvania
| | - Hansen Deng
- 2University of Pittsburgh Medical Center, School of Medicine, Pittsburgh, Pennsylvania
| | - Daipayan Guha
- 3Department of Surgery, Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Nitin Agarwal
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Alp Ozpinar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Harry M Mushlin
- 5Department of Neurological Surgery, Stony Brook University, Stony Brook, New York
| | - Lauren Puccio
- 2University of Pittsburgh Medical Center, School of Medicine, Pittsburgh, Pennsylvania
| | - David K Hamilton
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - David O Okonkwo
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Adam S Kanter
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
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DiMaria S, Karamian BA, Siegel N, Lambrechts MJ, Grewal L, Jeyamohan HR, Robinson WA, Patel A, Canseco JA, Kaye ID, Woods BI, Radcliff KE, Kurd MF, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Does Interbody Cage Lordosis and Position Affect Radiographic Outcomes After Single-level Transforaminal Lumbar Interbody Fusion? Clin Spine Surg 2022; 35:E674-E679. [PMID: 35383604 DOI: 10.1097/bsd.0000000000001334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/01/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to determine if the degree of interbody cage lordosis and cage positioning are associated with changes in postoperative sagittal alignment after single-level transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA Ideal sagittal alignment and lumbopelvic alignment have been shown to correlate with postoperative clinical outcomes. TLIF is one technique that may improve these parameters, but whether the amount of cage lordosis improves either segmental or lumbar lordosis (LL) is unknown. METHODS A retrospective review was performed on patients who underwent single-level TLIF with either a 5-degree or a 12-degree lordotic cage. LL, segmental lordosis (SL), disk height, center point ratio, cage position, and cage subsidence were evaluated. Correlation between center point ratio and change in lordosis was assessed using the Spearman correlation coefficient. Secondary analysis included multiple linear regression to determine independent predictors of change in SL. RESULTS A total of 126 patients were included in the final analysis, with 51 patients receiving a 5-degree cage and 75 patients receiving a 12-degree cage. There were no differences in the postoperative minus preoperative LL (∆LL) (12-degree cage: -1.66 degrees vs. 5-degree cage: -2.88 degrees, P =0.528) or ∆SL (12-degree cage: -0.79 degrees vs. 5-degree cage: -1.68 degrees, P =0.513) at 1-month follow-up. Furthermore, no differences were found in ∆LL (12-degree cage: 2.40 degrees vs. 5-degree cage: 1.00 degrees, P =0.497) or ∆SL (12-degree cage: 1.24 degrees vs. 5-degree cage: 0.35 degrees, P =0.541) at final follow-up. Regression analysis failed to show demographic factors, cage positioning, or cage lordosis to be independent predictors of change in SL. No difference in subsidence was found between groups (12-degree cage: 25.5% vs. 5-degree cage: 32%, P =0.431). CONCLUSION Lordotic cage angle and cage positioning were not associated with perioperative changes in LL, SL, or cage subsidence after single-level TLIF. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephen DiMaria
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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Hu YH, Yeh YC, Niu CC, Hsieh MK, Tsai TT, Chen WJ, Lai PL. Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion. J Neurosurg Spine 2022; 37:654-662. [PMID: 35561693 DOI: 10.3171/2022.3.spine211489] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decreased bone mineral density as measured by dual-energy x-ray absorptiometry (DEXA) has been reported to be associated with cage subsidence following transforaminal lumbar interbody fusion (TLIF). However, DEXA is not often available or routinely performed before surgery. A novel MRI-based vertebral bone quality (VBQ) score has been developed and reported to be correlated with DEXA T-scores. The authors investigated the ability of the VBQ score to predict cage subsidence and other risk factors associated with this complication. METHODS In this retrospective study, the authors reviewed the records of patients who had undergone single-level TLIF from March 2014 to October 2015 and had a follow-up of more than 2 years. Cage subsidence was measured as postoperative disc height loss and was graded according to the system proposed by Marchi et al. The MRI-based VBQ score was measured on T1-weighted images. Univariable analysis and multivariable binary logistic regression analysis were performed. Ad hoc analysis with receiver operating characteristic curve analysis was performed to assess the predictive ability of the significant continuous variables. Additional analyses were used to determine the correlations between the VBQ score and T-scores and between the significant continuous variables and the amount of cage subsidence. RESULTS Among 242 patients eligible for study inclusion, 111 (45.87%) had cage subsidence after the index operation. Multivariable logistic regression analyses demonstrated that an increased VBQ score (OR 14.615 ± 0.377, p < 0.001), decreased depth ratio (OR 0.011 ± 1.796, p = 0.013), and the use of kidney-shaped cages instead of bullet-shaped cages (OR 2.766 ± 0.358, p = 0.008) were associated with increased cage subsidence. The VBQ score was shown to significantly predict cage subsidence with an accuracy of 85.6%. The VBQ score was found to be moderately correlated with DEXA T-scores of the total hip (r = -0.540, p < 0.001) and the lumbar spine (r = -0.546, p < 0.001). The amount of cage subsidence was moderately correlated with the VBQ score (r = 0.512, p < 0.001). CONCLUSIONS Increased VBQ scores, posteriorly placed cages, and kidney-shaped cages were risk factors for cage subsidence. The VBQ score was shown to be a good predictor of cage subsidence, was moderately correlated with DEXA T-scores for the total hip and lumbar spine, and also had a moderate correlation with the amount of cage subsidence.
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Affiliation(s)
- Yung-Hsueh Hu
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
| | - Yu-Cheng Yeh
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
| | - Chi-Chien Niu
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
| | - Ming-Kai Hsieh
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
| | - Tsung-Ting Tsai
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
| | - Wen-Jer Chen
- 4Department of Orthopedic Surgery, Chung Shan Hospital, Taipei, Taiwan
| | - Po-Liang Lai
- 1Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou
- 2Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou
- 3College of Medicine, Chang Gung University, Taoyuan; and
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Lambrechts MJ, Siegel N, Heard JC, Karamian BA, Dambly J, Baker S, Brush P, Fras S, Canseco JA, Kaye ID, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Trends in Single-Level Lumbar Fusions Over the Past Decade Using a National Database. World Neurosurg 2022; 167:e61-e69. [PMID: 35963610 DOI: 10.1016/j.wneu.2022.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To compare rates of different fusion techniques using a nationwide database over the last decade and identify differences in complications and readmissions based on fusion technique. METHODS All elective, single-level lumbar fusions performed by orthopaedic surgeons from 2011 to 2020 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Rates of lumbar fusion technique posterolateral decompression and fusion [PLDF], combined transforaminal lumbar interbody fusion and PLDF, anterior lumbar or lateral lumbar interbody fusion [ALIF/LLIF], and combined ALIF/LLIF and PLDF were recorded, and 30-day complications and readmissions were compared. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS Inclusion criteria were met by 28,413 fusions: 8749 (30.8%) PLDFs, 11,973 (42.1%) transforaminal lumbar interbody fusions, 4769 (16.8%) ALIF/LLIFs, and 2922 (10.3%) combined ALIF/LLIF and PLDFs. The number of fusions increased over time with 1227 fusions performed in 2011 and 3958 fusions performed in 2019. Interbody fusions also increased over time with a subsequent decrease in PLDFs (39.0% in 2011, 25.2% in 2020). Patients were more likely to be discharged home over the course of the decade (85.4% in 2011, 95.0% in 2020). No difference was observed between the techniques regarding complications or readmissions. The modified 5-item frailty index was predictive of complications (odds ratio, 2.05; P = 0.001) and readmissions (odds ratio, 2.61; P < 0.001). CONCLUSIONS Lumbar fusions have continued to increase over the last decade with an increasing proportion of interbody fusions. Complications and readmissions appear to be driven by patient comorbidity and not fusion technique.
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Affiliation(s)
- Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julia Dambly
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sydney Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parker Brush
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sebastian Fras
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Wang X, Liu H, Wang W, Sun Y, Zhang F, Guo L, Li J, Zhang W. Comparison of Posterior Pedicle Screw Fixation and Lateral Fixation in the Extreme Lateral Interbody Fusion in Lumbar Degenerative Disease Patients with Osteopenia or Osteoporosis. Orthop Surg 2022; 14:3283-3292. [PMID: 36274218 PMCID: PMC9732588 DOI: 10.1111/os.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Nowadays, with the increasing proportion of osteoporosis in patients with lumbar degenerative diseases, doctors are facing the choice of intraoperative internal fixation methods. The purpose of this study was to compare and assess the clinical results of posterior bilateral pedicle screw fixation and lateral fixation in the extreme lateral interbody fusion (XLIF) in patients with osteopenia or osteoporosis. METHODS The retrospective review was performed on 67 degenerative lumbar diseases patients with osteopenia or osteoporosis who underwent XLIF in our hospital from January 2018 to July 2021. Patients in this study were classified into lateral screw (LS) group, lateral self-locking plate (LP) group, and bilateral pedicle screw (BPS) group. The functional evaluation factors containing Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) of leg pain, and VAS of low back pain, radiological factors such as disc height (DH), lumbar lordotic (LL) angle, segmental lordotic (SL) angle, cage subsidence degree and interbody fusion degree were compared. RESULTS Primary outcomes: no differences were observed with regards to the incidence of complications among LS, LP and BS group (P < 0.05). The JOA and leg pain VAS were significantly improved after operation (P < 0.05) and all groups demonstrated similar improvements in the leg pain VAS and JOA score (P > 0.05). When comparing VAS of leg pain and JOA scores, no differences were identified among LS, LP and BPS groups (P > 0.05). There are four thigh sensory complaint, one hip flexor weakness and one thigh pain occurred and no death was observed. There were significantly better DH, LL angle, SL angle, cage subsidence degree and interbody fusion degree in the BPS group than in LS and LP groups 1 year after surgery (P < 0.05). The DH loss ratio, LL angle loss ratio, SL angle loss ratio in the BPS group was significantly lower than in the LP and LS groups (P < 0.05). The 12-month SL angle improvement rate in the BPS group was significantly higher than in the LP and LS groups (20.20 ± 14.69, 0.73 ± 4.68, 6.20 ± 12.31, P < 0.05). SECONDARY OUTCOMES the BPS patients had significantly worse intraoperative blood loss and operation time than LS and LP patients (P < 0.05). CONCLUSION In lumbar diseases patients with osteopenia or osteoporosis, the bilateral pedicle screw fixation has better orthopedic effect than lateral internal fixation, and can better maintain the stability of the spine in the long-term follow-up, which is a better choice in XLIF surgery.
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Affiliation(s)
- Xianzheng Wang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Huanan Liu
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Weijian Wang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Yapeng Sun
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Fei Zhang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lei Guo
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Jiaqi Li
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Wei Zhang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
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Chen C, Li Q, Wang W, Ji C, Kang Y, Wang C, Zhang H, Zhang M, Zhou H, Feng H, Feng S. Comparison of the efficacy of expandable interbody fusion cage (EXP-IFC) and non-expandable interbody fusion cage (NE-IFC) in MIS-TLIF for lumbar degenerative diseases: A systematic retrospective study on 62 patients. Front Surg 2022; 9:1008171. [PMID: 36329978 PMCID: PMC9622769 DOI: 10.3389/fsurg.2022.1008171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/22/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES To investigate the clinical and radiographic outcomes of EXP-IFC in single-level MIS-TLIF. METHODS This study included patients aged ≥18 years who received a single-level MIS-TLIF procedure with at least 1 year of follow-up. Outcome measures: clinical features, preoperative and neurological complications. Imaging analysis included disc height (DH) restoration, surgical and contralateral side foraminal height (FH), lumbar lordosis angle (LL), segmental lordosis (SL). Visual analog scale (VAS) score for low back pain (VAS-LBP) and leg pain (VAS-LP), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) score were used to evaluate clinical outcomes. Statistical analysis was performed using independent sample t-test and sample t-test. The significance was set to p < 0.05 in univariate analysis. RESULTS A total of 62 patients undergoing single level MIS-TLIFs between January 2017 and January 2019 were included, with 32 NE-IFC 46.9% female, mean age 54.86 ± 11.65, mean body mass index (BMI) 24.59 ± 3.63) and 30 EXP (40% female, mean age 58.32 ± 12.99, mean BMI 24.45 ± 2.76) with no significant differences in demographics. There were no significant differences between two groups in Operative time (OT), Estimated blood loss (EBL) and Length of stay (LOS). No significant differences were found in VAS-LBP, VAS-LP, JOA and ODI in post-operation and the last follow-up between the two groups. The imaging outcome demonstrated that the mean increase in DH was significantly greater for the patients with EXP-IFC than those with NE-IFC group at 1 year follow-up (8.92 ± 0.51 mm EXP-IFC vs. 7.96 ± 0.96 mm NE-IFC, p < 0.001). The mean change in FH of operative and contralateral sides were observed to be significantly higher for the patients with EXP-IFC at 1 year follow-up (operative side:17.67 ± 2.29 mm EXP-IFC vs. 16.01 ± 2.73 mm NE-IFC, p = 0.042; contralateral side:17.32 ± 2.26 mm EXP-IFC vs. 16.10 ± 2.32 mm NE-IFC, p < 0.001), but changes in LL and SL were not significantly different. At the last follow-up, we did not find any significant difference in the fusion rate between the two groups. CONCLUSION Our results indicated that there may be no significant difference in short-term clinical outcomes between EXP-IFC and NE-IFC, but the use of EXP-IFC in MIS-TLIF can provide a significant restoration of disc height, and neural foraminal height compared to NE-IFC.
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Affiliation(s)
- Chen Chen
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Li
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wang
- Department of Orthopaedics, Qilu Hospital, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chunlei Ji
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Yi Kang
- Department of Orthopaedics, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin Medical University General Hospital, Tianjin, China
| | - Chaoyu Wang
- Department of Orthopaedics, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyi Zhang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Zhang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hengxing Zhou
- Department of Orthopaedics, Qilu Hospital, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China,Correspondence: Hengxing Zhou Haoyu Feng Shiqing Feng
| | - Haoyu Feng
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Correspondence: Hengxing Zhou Haoyu Feng Shiqing Feng
| | - Shiqing Feng
- Department of Orthopaedics, Qilu Hospital, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China,Department of Orthopaedics, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin Medical University General Hospital, Tianjin, China,Correspondence: Hengxing Zhou Haoyu Feng Shiqing Feng
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Nan C, Ma Z, Liu Y, Ma L, Li J, Zhang W. Impact of cage position on biomechanical performance of stand-alone lateral lumbar interbody fusion: a finite element analysis. BMC Musculoskelet Disord 2022; 23:920. [PMID: 36258213 PMCID: PMC9578219 DOI: 10.1186/s12891-022-05873-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to compare the biomechanical performance of various cage positions in stand-alone lateral lumbar interbody fusion(SA LLIF). Methods An intact finite element model of the L3-L5 was reconstructed. The model was verified and analyzed. Through changing the position of the cage, SA LLIF was established in four directions: anterior placement(AP), middle placement(MP), posterior placement(PP), oblique placement(OP). A 400 N vertical axial pre-load was imposed on the superior surface of L3 and a 10 N/m moment was applied on the L3 superior surface along the radial direction to simulate movements of flexion, extension, lateral bending, and axial rotation. Various biomechanical parameters were evaluated for intact and implanted models in all loading conditions, including the range of motion (ROM) and maximum stress. Results In the SA LLIF models, the ROM of L4-5 was reduced by 84.21–89.03% in flexion, 72.64–82.26% in extension, 92.5-95.85% in right and left lateral bending, and 87.22–92.77% in right and left axial rotation, respectively. Meanwhile, ROM of L3-4 was mildly increased by an average of 9.6% in all motion directions. Almost all stress peaks were increased after SA LLIF, including adjacent disc, facet joints, and endplates. MP had lower stress peaks of cage and endplates in most motion modes. In terms of the stress on facet joints and disc of the cephalad segment, MP had the smallest increment. Conclusion In our study, SA LLIF risked accelerating the adjacent segment degeneration. The cage position had an influence on the distribution of endplate stress and the magnitude of facet joint stress. Compared with other positions, MP had the slightest effect on the stress in the adjacent facet joints. Meanwhile, MP seems to play an important role in reducing the risk of cage subsidence.
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Affiliation(s)
- Chong Nan
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 050000, Shijiazhuang, Hebei Province, China
| | - Zhanbei Ma
- Department of Orthopedic, Central Hospital, Baoding No. 1, 071000, Baoding, Hebei Province, China
| | - Yuxiu Liu
- Department of Orthopedic, Central Hospital, Baoding No. 1, 071000, Baoding, Hebei Province, China
| | - Liang Ma
- Department of Orthopedic, Central Hospital, Baoding No. 1, 071000, Baoding, Hebei Province, China
| | - Jiaqi Li
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 050000, Shijiazhuang, Hebei Province, China
| | - Wei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 050000, Shijiazhuang, Hebei Province, China.
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Wang W, Xiao B, Wang H, Qi J, Gu X, Yu J, Ye X, Xu G, Xi Y. Oblique lateral interbody fusion stand-alone vs. combined with percutaneous pedicle screw fixation in the treatment of discogenic low back pain. Front Surg 2022; 9:1013431. [PMID: 36299573 PMCID: PMC9589912 DOI: 10.3389/fsurg.2022.1013431] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022] Open
Abstract
Objective Oblique lateral interbody fusion (OLIF) has unique advantages in the treatment of discogenic low back pain (DBP). However, there are few studies in this area, and no established standard for additional posterior internal fixation. The purpose of this study was to investigate the efficacy of OLIF stand-alone vs. combined with percutaneous pedicle screw fixation (PPSF) in the treatment of DBP. Methods This retrospective case-control study included forty patients. All patients were diagnosed with DBP by discography and discoblock. Perioperative parameters (surgery duration, blood loss, and muscle damage), complications, Visual analog scale (VAS), and Oswestry Disability Index (ODI) were assessed. Imaging data including cage subsidence, cage retropulsion, fusion rate, and adjacent spondylosis degeneration (ASD) were analyzed. Results There were 23 patients in the OLIF stand-alone group and 17 patients in the OLIF + PPSF group. The mean surgery duration, blood loss, and muscle damage in the OLIF stand-alone group were significantly better than those in the OLIF + PPSF group (P < 0.05). However, there was no significant difference in the average hospitalization time between the two groups (P > 0.05). There was no significant difference in the VAS and ODI scores between the two groups before surgery (P > 0.05), and VAS and ODI scores significantly improved after surgery (P < 0.05). The VAS and ODI scores in the OLIF stand-alone group were significantly better than those in the OLIF + PPSF group at 1 month (P < 0.05), While there was no significant difference between the two groups at 12 months and last follow up (P > 0.05). At the last follow-up, there was no significant difference in cage subsidence, fusion rate, ASD and complication rate between the two groups (P > 0.05). Conclusion OLIF stand-alone and OLIF + PPSF are both safe and effective in the treatment of DBP, and there is no significant difference in the long-term clinical and radiological outcomes. OLIF stand-alone has the advantages of surgery duration, blood loss, muscle damage, and early clinical effect. More clinical data are needed to confirm the effect of OLIF stand-alone on cage subsidence and ASD. This study provides a basis for the clinical application of standard DBP treatment with OLIF.
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Affiliation(s)
- Weiheng Wang
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Bing Xiao
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Haotian Wang
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Junqiang Qi
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xin Gu
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiangming Yu
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojian Ye
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guohua Xu
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yanhai Xi
- Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Muacevic A, Adler JR. Excessive Fluid in the Lumbar Facet Joint as a Predictor of Radiological Outcomes After Lateral Lumbar Interbody Fusion. Cureus 2022; 14:e30217. [PMID: 36381790 PMCID: PMC9650774 DOI: 10.7759/cureus.30217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/12/2022] [Indexed: 01/24/2023] Open
Abstract
Background Preoperative segmental instability maybe a predictor of postoperative outcomes when treated with lateral lumbar interbody fusion (LLIF). An abnormal collection of fluid within the facet joint has been described as a sign of segmental instability. The potential relationship between this radiological sign and its prognostic relevance for indirect decompression (ID) has not been investigated. Methods Clinical and radiologic results from patients undergoing LLIF in a single institution between 2007 and 2014 were evaluated retrospectively. Patients were divided into two groups: those presenting with excessive fluid (EF) in the facet joints on T2-MRI and those with a normal amount of facet fluid with less than 1mm, which were controls. Radiological parameters were foraminal height, disc height, Cobb angle, and lumbar lordosis. Results A total of 21 patients (43 operated levels) were evaluated pre- and postoperatively. Mean disc height, mean foraminal height, and coronal Cobb angles were statistically significantly improved after LLIF. Only the EF group showed significant improvement in radiological markers after ID; the mean disc height improved from 5.5±2 to 8.8±1mm (p=0.001), mean foraminal height improved from 16.88±3 to 20.53±3mm (p=0.002), and the mean Cobb angle improved from 27.7±16 to 14±13 (p=0.018). Conclusions Patients undergoing LLIF with the radiological findings of EF in the facet joints demonstrated significant improvement in radiological outcomes of ID. Further studies should validate these findings in larger data sets.
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Bhatti AUR, Cesare J, Wahood W, Alvi MA, Onyedimma CE, Ghaith AK, Akinnusotu O, El Sammak S, Freedman BA, Sebastian AS, Bydon M. Assessing the differences in operative and patient-reported outcomes between lateral approaches for lumbar fusion: a systematic review and indirect meta-analysis. J Neurosurg Spine 2022; 37:498-514. [PMID: 35453114 DOI: 10.3171/2022.2.spine211164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior-to-psoas lumbar interbody fusion (ATP-LIF), more commonly referred to as oblique lateral interbody fusion, and lateral transpsoas lumbar interbody fusion (LTP-LIF), also known as extreme lateral interbody fusion, are the two commonly used lateral approaches for performing a lumbar fusion procedure. These approaches help overcome some of the technical challenges associated with traditional approaches for lumbar fusion. In this systematic review and indirect meta-analysis, the authors compared operative and patient-reported outcomes between these two select approaches using available studies. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, the authors conducted an electronic search using the PubMed, EMBASE, and Scopus databases for studies published before May 1, 2019. Indirect meta-analysis was conducted on fusion rate, cage movement (subsidence plus migration), permanent deficits, and transient deficits; results were depicted as forest plots of proportions (effect size [ES]). RESULTS A total of 63 studies were included in this review after applying the exclusion criteria, of which 26 studies investigated the outcomes of ATP-LIF, while 37 studied the outcomes of LTP-LIF. The average fusion rate was found to be similar between the two groups (ES 0.97, 95% CI 0.84-1.00 vs ES 0.94, 95% CI 0.91-0.97; p = 0.561). The mean incidence of cage movement was significantly higher in the ATP-LIF group compared with the LTP-LIF group (stand-alone: ES 0.15, 95% CI 0.06-0.27 vs ES 0.09, 95% CI 0.04-0.16 [p = 0.317]; combined: ES 0.18, 95% CI 0.07-0.32 vs ES 0.02, 95% CI 0.00-0.05 [p = 0.002]). The mean incidence of reoperations was significantly higher in patients undergoing ATP-LIF than in those undergoing LTP-LIF (ES 0.02, 95% CI 0.01-0.03 vs ES 0.04, 95% CI 0.02-0.07; p = 0.012). The mean incidence of permanent deficits was similar between the two groups (stand-alone: ES 0.03, 95% CI 0.01-0.06 vs ES 0.05, 95% CI 0.01-0.12 [p = 0.204]; combined: ES 0.03, 95% CI 0.01-0.06 vs ES 0.03, 95% CI 0.00-0.08 [p = 0.595]). The postoperative changes in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were both found to be higher for ATP-LIF relative to LTP-LIF (VAS: weighted average 4.11 [SD 2.03] vs weighted average 3.75 [SD 1.94] [p = 0.004]; ODI: weighted average 28.3 [SD 5.33] vs weighted average 24.3 [SD 4.94] [p < 0.001]). CONCLUSIONS These analyses indicate that while both approaches are associated with similar fusion rates, ATP-LIF may be related to higher odds of cage movement and reoperations as compared with LTP-LIF. Furthermore, there is no difference in rates of permanent deficits between the two procedures.
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Affiliation(s)
- Atiq Ur Rehman Bhatti
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph Cesare
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 4University of Wisconsin, Madison, Wisconsin
| | - Waseem Wahood
- 5Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida; and
| | - Mohammed Ali Alvi
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Chiduziem E Onyedimma
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abdul Karim Ghaith
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Sally El Sammak
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brett A Freedman
- 3Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- 3Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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The Efficacy of Trabecular Titanium Cages to Induce Reparative Bone Activity after Lumbar Arthrodesis Studied through the 18f-Naf PET/CT Scan: Observational Clinical In-Vivo Study. Diagnostics (Basel) 2022; 12:diagnostics12102296. [PMID: 36291986 PMCID: PMC9600853 DOI: 10.3390/diagnostics12102296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Titanium trabecular cages (TTCs) are emerging implants designed to achieve immediate and long-term spinal fixation with early osseointegration. However, a clear radiological and clinical demonstration of their efficacy has not yet been obtained. The purpose of this study was to evaluate the reactive bone activity of adjacent plates after insertion of custom-made titanium trabecular cages for the lumbar interbody with positron emission tomography (PET)/computed tomography (CT) 18F sodium fluoride (18F-NaF). Methods: This was an observational clinical study that included patients who underwent surgery for degenerative disease with lumbar interbody fusion performed with custom-made TTCs. Data related to the metabolic-reparative reaction following the surgery and its relationship with clinical follow-up from PET/CT performed at different weeks were evaluated. PET/CTs provided reliable data, such as areas showing abnormally high increases in uptake using a volumetric region of interest (VOI) comprising the upper (UP) and lower (DOWN) limits of the cage. Results: A total of 15 patients was selected for PET examination. Timing of PET/CTs ranged from one week to a maximum of 100 weeks after surgery. The analysis showed a negative correlation between the variables SUVmaxDOWN/time (r = −0.48, p = 0.04), ratio-DOWN/time (r = −0.53, p = 0.02), and ratio-MEAN/time (r = −0.5, p = 0.03). Shapiro−Wilk normality tests showed significant results for the variables ratio-DOWN (p = 0.002), ratio-UP (0.013), and ratio-MEAN (0.002). Conclusions: 18F-NaF PET/CT has proven to be a reliable tool for investigating the metabolic-reparative reaction following implantation of TTCs, demonstrating radiologically how this type of cage can induce reparative osteoblastic activity at the level of the vertebral endplate surface. This study further confirms how electron-beam melting (EBM)-molded titanium trabecular cages represent a promising material for reducing hardware complication rates and promoting fusion.
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Xie F, Yang Z, Tu Z, Huang P, Wang Z, Luo Z, Hu X. The value of Hounsfield units in predicting cage subsidence after transforaminal lumbar interbody fusion. BMC Musculoskelet Disord 2022; 23:882. [PMID: 36138360 PMCID: PMC9502605 DOI: 10.1186/s12891-022-05836-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cage subsidence may occur following transforaminal lumbar interbody fusion (TLIF) and lead to nonunion, foraminal height loss and other complications. Low bone quality may be a risk factor for cage subsidence. Assessing bone quality through Hounsfield units (HU) from computed tomography has been proposed in recent years. However, there is a lack of literature evaluating the correlation between HU and cage subsidence after TLIF. METHODS Two hundred and seventy-nine patients suffering from lumbar degenerative diseases from April, 2016 to August, 2018 were enrolled. All underwent one-level TLIF with a minimum of 1-year follow-up. Cage subsidence was defined as > 2 mm loss of disc height at the fusion level. The participants were divided into 2 groups: cage subsidence group (CS) and non-cage subsidence group (non-CS). Bone quality was determined by HU, bone mineral density of lumbar (BMD-l) and femoral (BMD-f) from dual-emission X-ray absorptiometry (DXA). HU of each vertebra from L1 to L4 (e.g., HU1 for HU of L1) and mean value of the four vertebrae (HUm) were calculated. Visual analog scale (VAS) of back/leg pain and Oswestry disability index (ODI) were used to report clinical outcomes. RESULTS Cage subsidence occurred in 82 (29.4%) cases at follow-ups. Mean age was 50.8 ± 9.0 years with a median follow-up of 18 months (range from 12 to 40 months). A total of 90.3% patients presented fusion with similar fusion rate between the two groups. ODI and VAS in leg were better in non-CS group at last follow-ups. Using receiver operating characteristic curves (ROCs) to predict cage subsidence, HUm provided a larger area under the curve (AUC) than BMD-l (Z = 3.83, P < 0.01) and BMD-f (Z = 2.01, P = 0.02). AUC for HU4 was larger than BMD-f and close to HUm (Z = 0.22, P = 0.481). CONCLUSIONS Cage subsidence may indicate worse clinical outcomes. HU value could be a more effective predictor of lumbar cage subsidence compared with T-score of DXA after TLIF.
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Affiliation(s)
- Fang Xie
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Zhiwei Yang
- Department of Orthopaedic Surgery, Air Force Hospital of Eastern Theater Command, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Zhipeng Tu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Peipei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Zhe Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Zhuojing Luo
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China.
| | - Xueyu Hu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Air Force Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China.
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Shi H, Wang XH, Zhu L, Chen L, Jiang ZL, Wu XT. Intraoperative Endplate Injury Following Transforaminal Lumbar Interbody Fusion. World Neurosurg 2022; 168:e110-e118. [PMID: 36122858 DOI: 10.1016/j.wneu.2022.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the incidence, distribution characteristics, risk factors, and clinical outcomes of intraoperative endplate injury following transforaminal lumbar interbody fusion (TLIF). METHODS Patients who underwent single-level TLIF from January 2018 to December 2020 were included. The patients were separated into endplate injury group (EI group) and no endplate injury group (non-EI group) by postoperative computed tomography scanning immediately. All patients' demographic, clinical, and radiographic parameters were analysed. Clinical outcomes were evaluated by visual analogue scale (VAS) for low back pain and Oswestry Disability Index (ODI). RESULTS 576 patients were enrolled in this study. The rates of endplate injury were 19.6% (113 of 576) of patients and 9.9% (114 of 1152) of endplates. The rate of superior endplate injury was significantly higher than that of inferior endplate injury. The results illustrated that older age, lower disc height index (DHI), and taller cage height were independent risk factors for intraoperative endplate injury. The postoperative drain output, total blood loss, postoperative duration of drainage tube, and postoperative hospital stay in EI group were significantly more than those in non-EI group. There were no statistical differences in ODI and VAS scores at the same time point between two groups. CONCLUSIONS The rates of endplate injury were 19.6% of patients and 9.9% of endplates. The superior endplates are more susceptible to injury than inferior endplates. Older age, lower DHI, and taller cage height were independent risk factors for intraoperative endplate injury. Clinical outcomes were not affected by intraoperative endplate injury during early postoperative follow-up.
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Affiliation(s)
- Hang Shi
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiao-Hu Wang
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lei Zhu
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lu Chen
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zan-Li Jiang
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiao-Tao Wu
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
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Tseng SC, Lin YH, Wu YC, Shih CM, Chen KH, Lee CH, Pan CC. Indirect decompression via oblique lumbar interbody fusion is sufficient for treatment of lumbar foraminal stenosis. Front Surg 2022; 9:911514. [PMID: 36061052 PMCID: PMC9433985 DOI: 10.3389/fsurg.2022.911514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
Oblique lumbar interbody fusion (OLIF) is a popular technique for the treatment of degenerative lumbar spinal disease. There are no clear guidelines on whether direct posterior decompression (PD) is necessary after OLIF. The purpose of this study was to analyze the effect of the indirect decompression obtained from OLIF in patients with lumbar foraminal stenosis. We retrospectively reviewed 33 patients who underwent OLIF surgery for degenerative lumbar spinal disease between 1 January 2018, and 30 June 2019. The inclusion criteria included patients who were diagnosed with lumbar foraminal stenosis by preoperative MRI. The exclusion criteria included the presence of central canal stenosis, spinal infection, vertebral fractures, and spinal malignancies. The clinical results, evaluated using the visual analogue scale of back pain (VAS-Back), VAS of leg pain (VAS-Leg), and Oswestry disability index (ODI), were recorded. The radiologic parameters were also measured. The VAS-Back, VAS-Leg, and ODI showed significant improvement in both the PD and non-posterior decompression (Non-PD) groups postoperatively (all, p < 0.05). Patients in the Non-PD group showed better results than those in the PD group in the VAS-Back at 12- and 24 months postoperatively (0.00 vs. 3.00 postoperatively at 12 months, p = 0.030; 0.00 vs. 4.00 postoperatively at 24 months, p = 0.009). In addition, the ODI at 24 months postoperatively showed better improvement in the Non-PD group (8.89 vs. 24.44, p = 0.038). The disc height in both the PD and the Non-PD groups increased significantly postoperatively (all, p < 0.05), but the restoration of foraminal height was significantly different only in the Non-PD group. There was no statistically significant difference in cage position, cage subsidence, fusion grade, or screw loosening between the PD and the Non-PD groups. Indirect decompression via OLIF for lumbar foraminal stenosis showed favorable outcomes. The use of interbody cages and posterior instrumentation was sufficient for relieving symptoms in patients with lumbar foraminal stenosis. Additional direct posterior decompression may deteriorate results in the follow-up period.
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Affiliation(s)
- Sheng-Chieh Tseng
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Hsien Lin
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yun-Che Wu
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Min Shih
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Physical Therapy, HungKuang University, Taichung, Taiwan
| | - Kun-Hui Chen
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
- Department of Computer Science and Information Engineering, College of Computing and Informatics, Providence University, Taichung, Taiwan
- Department of Biomedical Engineering, College of Intelligent Technology, HungKuang University, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan
| | - Chien-Chou Pan
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Rehabilitation Science, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
- Correspondence: Chien-Chou Pan
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Laubach M, Kobbe P, Hutmacher DW. Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions. Biomaterials 2022; 288:121699. [PMID: 35995620 DOI: 10.1016/j.biomaterials.2022.121699] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000, Australia.
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Prospective, Randomized, Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgeries. Spine (Phila Pa 1976) 2022; 47:1043-1054. [PMID: 35881014 DOI: 10.1097/brs.0000000000004361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 03/17/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, randomized, blinded clinical trial. OBJECTIVE To examine clinical and radiological outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) surgeries randomized to receive either polyether-ether-ketone (PEEK) or structural bone allografts. SUMMARY OF BACKGROUND DATA The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however, as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. METHODS Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12, and 24 months with an additional postoperative radiographic assessment. RESULTS A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted; however, there was a statistically significant (≤0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency toward lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (P = 0.72) in the PEEK and allograft groups, respectively. At 24 months' follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months' follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSION Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK versus allograft-assisted ACDF surgeries. Although MCID comparisons suggest that allograft and PEEK-treated patients have similar clinical outcomes, testing that incorporates the magnitude of the change suggests that there may be a statistically significant greater magnitude of improvement for the allograft group patients, but further studies with a larger sample size would be helpful to determine if a true effect exists.
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79
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Ohiorhenuan IE, Walker CT, Zhou JJ, Godzik J, Sagar S, Farber SH, Uribe JS. Predictors of subsidence after lateral lumbar interbody fusion. J Neurosurg Spine 2022; 37:183-187. [PMID: 35245900 DOI: 10.3171/2022.1.spine201893] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lateral lumbar interbody fusion (LLIF) facilitates the restoration of disc height and the indirect decompression of neural elements. However, these benefits are lost when the graft subsides into the adjacent endplates. The factors leading to subsidence after LLIF are poorly understood. This article presents a case series of patients who underwent LLIF and reports factors correlating with subsidence. METHODS A retrospective review of a consecutive, prospectively collected, single-institution database of patients who underwent LLIF over a 29-month period was performed. The degree of subsidence was measured on the basis of postoperative imaging. The timing of postoperative subsidence was determined, and intraoperative fluoroscopic images were reviewed to determine whether subsidence occurred as a result of endplate violation. The association of subsidence with age, sex, cage size and type, bone density, and posterior instrumentation was investigated. RESULTS One hundred thirty-one patients underwent LLIF at a total of 204 levels. Subsidence was observed at 23 (11.3%) operated levels. True subsidence, attributable to postoperative cage settling, occurred for 12 (5.9%) of the levels; for the remaining 11 (5.4%) levels, subsidence was associated with intraoperative endplate violation noted on fluoroscopy during cage placement. All subsidence occurred within 12 weeks of surgery. Univariate analysis showed that the prevalence of true subsidence was significantly lower among patients with titanium implants (0 of 55; 0%) than among patients with polyetheretherketone cages (12 of 149; 8.1%) (p = 0.04). In addition, the mean ratio of graft area to inferior endplate area was significantly lower among the subsidence levels (0.34) than among the nonsubsidence levels (0.42) (p < 0.01). Finally, subsidence among levels with posterior fixation (4.4% [6/135]) was not significantly different than among those without posterior fixation (8.7% [6/69]) (p = 0.23). Multivariate analysis results showed that the ratio of cage to inferior endplate area was the only significant predictor of subsidence in this study (p < 0.01); increasing ratios were associated with a decreased likelihood of subsidence. CONCLUSIONS Overall, the prevalence of subsidence after LLIF was low in this clinical series. Titanium cages were associated with a lower prevalence of observed subsidence on univariate analysis; however, multivariate analysis demonstrated that this effect may be attributable to the increased surface area of these cages relative to the inferior endplate area.
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80
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Xie T, Pu L, Zhao L, Lu Y, Yang Z, Wang X, Song Y, Zeng J. Influence of coronal-morphology of endplate and intervertebral space to cage subsidence and fusion following oblique lumbar interbody fusion. BMC Musculoskelet Disord 2022; 23:633. [PMID: 35788206 PMCID: PMC9252057 DOI: 10.1186/s12891-022-05584-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/24/2022] [Indexed: 02/08/2023] Open
Abstract
Background Endplate morphology is considered to be one of the influencing factors of cage subsidence after lumbar interbody fusion (LIF). Previous radiographic evaluations on the endplate mostly used sagittal X-ray or MRI. However, there are few studies on the CT evaluation of the endplate and intervertebral space (IVS), especially the evaluation of coronal morphology and its influence on subsidence and fusion after LIF. We aimed to measure and classify the shapes of the endplate and IVS using coronal CT imaging and evaluate the radiographic and clinical outcomes of different shapes of the endplate/IVS following oblique lateral lumbar interbody fusion (OLIF). Methods A total of 137 patients (average age 59.1 years, including 75 males and 62 females) who underwent L4-5 OLIF combined with anterolateral fixation from June 2018 to June 2020 were included. The endplate concavity depth (ECD) was measured on the preoperative coronal CT image. According to ECD, the endplate was classified as flat (< 2 mm), shallow (2–4 mm), or deep (> 4 mm). The L4-5 IVS was further classified according to endplate type. The disc height (DH), DH changes, subsidence rate, fusion rate, and Oswestry Disability Index (ODI) in different endplate/IVS shapes were evaluated during 1-year follow up. Results The ECD of L4 inferior endplate (IEP) was significantly deeper than that of L5 superior endplate (SEP) (4.2 ± 1.1 vs 1.6 ± 0.8, P < 0.01). Four types of L4-5 IVS were identified: shallow-shallow (16, 11.7%), shallow-flat (45, 32.9%), deep-shallow (32, 23.4%), and deep-flat (44, 32.1%). A total of 45 (32.9%) cases of cage subsidence were observed. Only one (6.3%) subsidence event occurred in the shallow-shallow group, which was significantly lower than in the other three groups (19 shallow-flat, 6 deep-shallow, and 19 deep-flat) (P < 0.05). Meanwhile, the shallow-shallow group had the highest fusion rate (15, 93.8%) and the highest rate of reach minimal clinically important difference (MCID) ODI among the four types. For a single endplate, the shape of L4 IEP is the main influencing factor of the final interbody fusion rate, and the shallow shape L4 IEP facilitates fusion ( OR = 2.85, p = 0.03). On the other hand, the flat shape L5 SEP was the main risk factor to cage subsidence (OR = 4.36, p < 0.01). Conclusion The L4-5 IVS is asymmetrical on coronal CT view and tends to be fornix-above and flat-down. The shallow-shallow IVS has the lowest subsidence rate and best fusion result, which is possibly because it has a relatively good degree in matching either the upper or lower interface of the cage and endplates. These findings provide a basis for the further improvements in the design of OLIF cages. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05584-3.
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Affiliation(s)
- Tianhang Xie
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Liming Pu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Long Zhao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Yufei Lu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Zhiqiang Yang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Xiandi Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Yueming Song
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Jiancheng Zeng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.
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Huang S, Min S, Wang S, Jin A. Biomechanical effects of an oblique lumbar interbody fusion combined with posterior augmentation: a finite element analysis. BMC Musculoskelet Disord 2022; 23:611. [PMID: 35761228 PMCID: PMC9235194 DOI: 10.1186/s12891-022-05553-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Oblique lateral interbody fusion (OLIF) is widely used to treat lumbar degenerative disc disease. This study aimed to evaluate the biomechanical stability of OLIF, OLIF including posterior pedicle screw and rod (PSR), and OLIF including cortical screw and rod (CSR) instrumentation through finite element analysis. Methods A complete L2-L5 finite element model of the lumbar spine was constructed. Surgical models of OLIF, such as stand-alone, OLIF combined with PSR, and OLIF combined with CSR were created in the L3-L4 surgical segments. Range of motion (ROM), end plate stress, and internal fixation peak stress were compared between different models under the same loading conditions. Results Compared to the intact model, ROM was reduced in the OLIF model under all loading conditions. The surgical models in order of increasing ROM were PSR, CSR, and stand-alone; however, the difference in ROM between BPS and CSR was less than 0.4° and was not significant under any loading conditions. The stand-alone model had the highest stress on the superior L4 vertebral body endplate under all loading conditions, whereas the end plate stress was relatively low in the BPS and CSR models. The CSR model had the highest internal fixation stress, concentrated primarily at the end of the screw. Conclusions OLIF alone significantly reduces ROM but does not provide sufficient stability. Addition of posterior PSR or CSR internal fixation instrumentation to OLIF surgery can significantly improve biomechanical stability of the segment undergoing surgery.
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Rapid Personalised Virtual Planning and On-Demand Surgery for Acute Spinal Trauma Using 3D-Printing, Biomodelling and Patient-Specific Implant Manufacture. J Pers Med 2022; 12:jpm12060997. [PMID: 35743781 PMCID: PMC9224763 DOI: 10.3390/jpm12060997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 12/04/2022] Open
Abstract
Three-dimensional printing is a rapidly growing field, with extensive application to orthopaedics and spinal surgery. Three-dimensional-printed (3DP) patient-specific implants (PSIs) offer multiple potential benefits over generic alternatives, with their use increasingly being described in the spinal literature. This report details a unique, emergency case of a traumatic spinal injury in a 31-year-old male, acquired rurally and treated with a 3DP PSI in a tertiary unit. With increasing design automation and process improvements, rapid, on-demand virtual surgical planning (VSP) and 3DP PSIs may present the future of orthopaedics and trauma care, enabling faster, safer, and more cost-effective patient-specific procedures.
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83
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Zhu G, Wu Z, Fang Z, Zhang P, He J, Yu X, Ge Z, Tang K, Liang D, Jiang X, Liang Z, Cui J. Effect of the In Situ Screw Implantation Region and Angle on the Stability of Lateral Lumbar Interbody Fusion: A Finite Element Study. Orthop Surg 2022; 14:1506-1517. [PMID: 35656700 PMCID: PMC9251290 DOI: 10.1111/os.13312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To investigate the effect of the in situ screw implantation region and angle on the stability of lateral lumbar interbody fusion (LLIF) from a biomechanical perspective. Methods A validated L2‐4 finite element (FE) model was modified for simulation. The L3‐4 fused segment undergoing LLIF surgery was modeled. The area between the superior and inferior edges and the anterior and posterior edges of the vertebral body (VB) is divided into four zones by three parallel lines in coronal and horizontal planes. In situ screw implantation methods with different angles based on the three parallel lines in coronal plane were applied in Models A, B, and C (A: parallel to inferior line; B: from inferior line to midline; C: from inferior line to superior line). In addition, four implantation methods with different regions based on the three parallel lines in horizontal plane were simulated as types 1–2, 1–3, 2–2, and 2–3 (1–2: from anterior line to midline; 1–3: from anterior line to posterior line; 2–2: parallel to midline; 2–3: from midline to posterior line). L3‐4 ROM, interbody cage stress, screw‐bone interface stress, and L4 superior endplate stress were tracked and calculated for comparisons among these models. Results The L3‐4 ROM of Models A, B, and C decreased with the extent ranging from 47.9% (flexion‐extension) to 62.4% (lateral bending) with no significant differences under any loading condition. Types 2–2 and 2–3 had 45% restriction, while types 1–2 and 1–3 had 51% restriction in ROM under flexion‐extension conditions. Under lateral bending, types 2–2 and 2–3 had 70.6% restriction, while types 1–2 and 1–3 had 61.2% restriction in ROM. Under axial rotation, types 2–2 and 2–3 had 65.2% restriction, while types 1–2 and 1–3 had 59.3% restriction in ROM. The stress of the cage in types 2–2 and 2–3 was approximately 20% lower than that in types 1–2 and 1–3 under all loading conditions in all models. The peak stresses at the screw‐bone interface in types 2–2 and 2–3 were much lower (approximately 35%) than those in types 1–2 and 1–3 under lateral bending, while no significant differences were observed under flexion‐extension and axial rotation. The peak stress on the L4 superior endplate was approximately 30 MPa and was not significantly different in all models under any loading condition. Conclusions Different regions of entry‐exit screws induced multiple screw trajectories and influenced the stability and mechanical responses. However, different implantation angles did not. Considering the difficulty of implantation, the ipsilateral‐contralateral trajectory in the lateral middle region of the VB can be optimal for in situ screw implantation in LLIF surgery.
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Affiliation(s)
- Guangye Zhu
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhihua Wu
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhichao Fang
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Peng Zhang
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiahui He
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiang Yu
- Department of Spinal Surgery, 1st Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhilin Ge
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kai Tang
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - De Liang
- Department of Spinal Surgery, 1st Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobing Jiang
- Department of Spinal Surgery, 1st Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziyang Liang
- 1st Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jianchao Cui
- Department of Spinal Surgery, 1st Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Manzur MK, Samuel AM, Morse KW, Shafi KA, Gatto BJ, Gang CH, Qureshi SA, Iyer S. Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review. Global Spine J 2022; 12:980-989. [PMID: 34011192 PMCID: PMC9344527 DOI: 10.1177/21925682211013011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression. METHODS A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance. RESULTS A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant (P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant (P = .053). CONCLUSIONS Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.
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Affiliation(s)
- Mustfa K. Manzur
- Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | | | | | - Sravisht Iyer
- Hospital for Special Surgery, New York,
NY, USA,Sravisht Iyer, Department of Orthopedic
Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021,
USA.
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85
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Hiyama A, Katoh H, Nomura S, Sakai D, Watanabe M. The Effect of Preoperative Neuropathic Pain and Nociceptive Pain on Postoperative Pain Intensity in Patients with the Lumbar Degenerative Disease Following Lateral Lumbar Interbody Fusion. World Neurosurg 2022; 164:e814-e823. [PMID: 35598851 DOI: 10.1016/j.wneu.2022.05.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze whether the type of preoperative pain affects the improvement in postoperative pain intensity in patients with a lumbar degenerative disease (LDD). METHODS We retrospectively reviewed 93 patients who underwent lateral lumbar interbody fusion (LLIF) without direct decompression. All patients were evaluated using Numeric Rating Scale (NRS) scores for low back pain (NRSLBP), leg pain (NRSLP), and leg numbness (NRSLN) and imaging data before and after LLIF surgery. Based on the Japanese version of the painDETECT scores, patients were classified into 3 groups: a neuropathic pain (NeP) group, a nociceptive pain (NocP) group, and an intermediate mixed pain group. RESULTS The Japanese version of the painDETECT identified NeP in 20.4% of patients with LDD prior to LLIF. Preoperative NRSLBP, NRSLP, and NRSLN scores were higher in the NeP group than those in the NocP group. All types of pain improved after LLIF surgery. The NRSLBP score 12 months after surgery was higher in the NeP group (3.8 ± 2.8) than that in the NocP group (1.9 ± 2.2) (P = 0.008). Similar results were obtained with NRSLP (NeP group = 3.1 ± 2.8, NocP group = 1.5 ± 2.0, P = 0.010). CONCLUSIONS Although LLIF was useful for relieving all types of preoperative pain in LDD patients, the NRS scores for preoperative pain were higher in the NeP group than those in the NocP group, and the postoperative NRSLBP and NRSLP score was significantly higher in the NeP group. Thus, controlling preoperative NeP may improve therapeutic efficacy.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Satoshi Nomura
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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86
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Zhao L, Xie T, Wang X, Yang Z, Pu X, Zeng J. Whether Anterolateral Single Rod Can Maintain the Surgical Outcomes Following Oblique Lumbar Interbody Fusion for Double-Segment Disc Disease. Orthop Surg 2022; 14:1126-1134. [PMID: 35478325 PMCID: PMC9163980 DOI: 10.1111/os.13290] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 02/05/2023] Open
Abstract
Objective To evaluate the outcomes of oblique lumbar interbody fusion (OLIF) combined with anterolateral single‐rod screw fixation (AF) in treating two‐segment lumbar degenerative disc disease (LDDD) and to determine whether AF can maintain the surgical results. Methods A retrospective analysis was performed on patients who underwent OLIF combined with AF (OLIF‐AF) for LDDD at the L3‐5 levels between October 2017 and May 2018. A total of 84 patients, including 44 males and 40 females, with a mean age of 62.8 ± 6.8 years, who completed the 12‐month follow‐up were eventually enrolled. Clinical outcomes, including the Oswestry Disability Index (ODI), visual analog scale (VAS) score for the low back and leg, and radiographic parameters, including the cross‐sectional area (CSA) of the spinal canal, disc height (DH), foraminal height (FH), degree of upper vertebral slippage (DUVS), segmental lumbar lordosis (SL), fusion rate, and lumbar lordosis (LL), were recorded before surgery and 1 and 12 months after surgery. Surgical‐related complications, including cage subsidence (CS), were also evaluated. The local radiographic parameters were compared between L3‐4 and L4‐5. The clinical results and all radiographic parameters were compared between patients with and without CS. Results Significant improvements were observed in radiographic parameters 1 day postoperatively (p < 0.05). Local radiological parameters in L4‐5 had a significant decrease at 12 months postoperatively (p < 0.05), while they were well‐maintained at L3‐4 throughout the follow‐up period (p > 0.05). CS was observed in 26 segments (15.5%). Endplate injury was observed in four segments (2.4%). There was no significant difference in the fusion rate between the segments with and without CS (p = 0.355). The clinical results improved significantly after surgery (p < 0.05), and no significant difference was observed between the groups with and without CS (p > 0.05). Conclusions Anterolateral fixation combined with OLIF provides sufficient stability to sustain most radiological improvements in treating double‐segment LDDD. Subsidence was the most common complication, which was prone to occur in L4‐5 compared to L3‐4, but did not impede the fusion process or diminish the surgical results.
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Affiliation(s)
- Long Zhao
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Tianhang Xie
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xiandi Wang
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiqiang Yang
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xingxiao Pu
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jiancheng Zeng
- Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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87
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Zhou J, Yuan C, Liu C, Liu M, Zhou L, Wang J. Assessment of vertebral bone mineral density and stand-alone oblique lumbar interbody fusion for adjacent segment disease and primary lumbar degenerative diseases. J Orthop Surg (Hong Kong) 2022; 30:10225536221091846. [PMID: 35410526 DOI: 10.1177/10225536221091846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the vertebral bone mineral density and the value of stand-alone oblique lumbar interbody fusion (SA OLIF) for the management of single-level adjacent segment disease (ASD) and primary lumbar degenerative diseases. PATIENTS AND METHODS Seventy-eight patients undergoing single-level SA OLIF was divided into index surgery group (n = 36) or revision surgery group (n = 42) at single center. The vertebral body Hounsfield units (HU) value was measured to assess bone mineral density of operated level by the preoperative CT. The following data were retrospectively collected and compared between the two groups: demographic, surgical data, clinical results, and complications. RESULTS No differences were found between the two groups in surgical data. The fusion segment HU values in the revision group were significantly higher than that in the index group (147.4 ± 35.3 vs 129.2 ± 38.4 p = .033). There were significant differences while comparing fusion segment HU values to L1-L4 horizontal plane (147.4 ± 35.3 vs 126.1 ± 28.4, p = .000) and L1 (147.4 ± 35.3 vs 126.8 ± 26.2, p = .000) in revision group, meanwhile, no statistically significant difference was observed in index group (p > .05). The cage subsidence was observed in the revision group (n = 2) and index group (n = 9) (p = .045). The patients with cage subsidence had significantly lower vertebral HU values. CONCLUSION SA OLIF is valid alternative to the traditional posterior approach in the management of ASD with good clinical outcomes at short-term follow-up. Increased HU values of fusion segment may play a role in the management of ASD by SA OLIF.
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Affiliation(s)
- Jing Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Yuan
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Minghan Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Lei Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Jian Wang
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
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88
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Khan I, Parker SL, Bow H, Sivaganesan A, Pennings JS, Stephens II BF, Steinle AM, Gupta R, Devin CJ. Clinical and Cost-Effectiveness of Lumbar Interbody Fusion Using Tritanium Posterolateral Cage (vs. Propensity-Matched Cohort of PEEK Cage). Spine Surg Relat Res 2022; 6:671-680. [PMID: 36561152 PMCID: PMC9747220 DOI: 10.22603/ssrr.2021-0252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/05/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Surgical management of degenerative lumbar spine disorders is effective at improving patient pain, disability, and quality of life; however, obtaining a durable posterolateral fusion after decompression remains a challenge. Interbody fusion technologies are viable means of improving fusion rates in the lumbar spine, specifically various graft materials including autograft, structural allograft, titanium, and polyether ether ketone. This study assesses the effectiveness of Tritanium posterolateral cage in the treatment of degenerative disk disease. Methods Nearest-neighbor 1:1 matched control transforaminal lumbar interbody fusion with PEEK vs. Tritanium posterior lumbar (PL) cage interbody fusion patients were identified using propensity scoring from patients that underwent elective surgery for degenerative disk diseases. Line graphs were generated to compare the trajectories of improvement in patient-reported outcomes (PROs) from baseline to 3 and 12 months postoperatively. The nominal data were compared via the χ2 test, while the continuous data were compared via Student's t-test. Results The two groups had no difference regarding either the 3- or 12-month Euro-Qol-5D (EQ-5D), numeric rating scale (NRS) leg pain, and NRS back pain; however, the Tritanium interbody cage group had better Oswestry Disability Index (ODI) scores compared to the control group of the PEEK interbody cage at both 3 and 12 months (p=0.013 and 0.048). Conclusions Our results indicate the Tritanium cage is an effective alternative to the previously used PEEK cage in terms of PROs, surgical safety, and radiological parameters of surgical success. The Tritanium cohort showed better ODI scores, higher fusion rates, lower subsidence, and lower indirect costs associated with surgical management, when compared to the propensity-matched PEEK cohort.
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Affiliation(s)
- Inamullah Khan
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Scott L. Parker
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Hansen Bow
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Jacquelyn S. Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Byron F. Stephens II
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Anthony M. Steinle
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States
| | - Rishabh Gupta
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, United States,University of Minnesota Medical School, Minneapolis, United States
| | - Clinton J. Devin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, United States,Steamboat Orthopaedic and Spine Institute, Steamboat Springs, United States
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89
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Yu Y, Robinson DL, Ackland DC, Yang Y, Lee PVS. Influence of the geometric and material properties of lumbar endplate on lumbar interbody fusion failure: a systematic review. J Orthop Surg Res 2022; 17:224. [PMID: 35399075 PMCID: PMC8996478 DOI: 10.1186/s13018-022-03091-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background Lumbar interbody fusion (LIF) is an established surgical intervention for patients with leg and back pain secondary to disc herniation or degeneration. Interbody fusion involves removal of the herniated or degenerated disc and insertion of interbody devices with bone grafts into the remaining cavity. Extensive research has been conducted on operative complications such as a failure of fusion or non-union of the vertebral bodies. Multiple factors including surgical, implant, and patient factors influencing the rate of complications have been identified. Patient factors include age, sex, osteoporosis, and patient anatomy. Complications can also be influenced by the interbody cage design. The geometry of the bony endplates as well as their corresponding material properties guides the design of interbody cages, which vary considerably across patients with spinal disorders. However, studies on the effects of such variations on the rate of complications are limited. Therefore, this study aimed to perform a systematic review of lumbar endplate geometry and material property factors in LIF failure. Methods Search keywords included ‘factor/cause for spinal fusion failure/cage subsidence/cage migration/non-union’, ‘lumbar’, and ‘interbody’ in electronic databases PubMed and Scopus with no limits on year of publication. Results In total, 1341 articles were reviewed, and 29 articles were deemed suitable for inclusion. Adverse events after LIF, such as cage subsidence, cage migration, and non-union, resulted in fusion failure; hence, risk factors for adverse events after LIF, notably those associated with lumbar endplate geometry and material properties, were also associated with fusion failure. Those risk factors were associated with shape, concavity, bone mineral density and stiffness of endplate, segmental disc angle, and intervertebral disc height. Conclusions This review demonstrated that decreased contact areas between the cage and endplate, thin and weak bony endplate as well as spinal diseases such as spondylolisthesis and osteoporosis are important causes of adverse events after LIF. These findings will facilitate the selection and design of LIF cages, including customised implants based on patient endplate properties. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03091-8.
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90
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Wang Y, Wang J, Tu S, Li S, Yi J, Zhao H, Qiao H, Yan K, Liao B. Biomechanical Evaluation of an Oblique Lateral Locking Plate System for Oblique Lumbar Interbody Fusion: A Finite Element Analysis. World Neurosurg 2022; 160:e126-e141. [PMID: 35031519 DOI: 10.1016/j.wneu.2021.12.105] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The oblique lateral locking plate system (OLLPS) is a novel internal fixation with a locking and reverse pedicle track screw configuration designed for oblique lumbar interbody fusion (OLIF). The OLLPS is placed in a single position through the oblique lateral surgical corridor to reduce operative time and complications associated with prolonged anesthesia and prone positioning. The purpose of this study was to verify the biomechanical effect of the OLLPS. METHODS An intact finite element model of L1-S1 (intact) was established based on computed tomography images of a healthy male volunteer. The L4-L5 intervertebral space was selected as the surgical segment. The surgical models were established separately based on OLIF surgical procedures and different internal fixations: 1) stand-alone OLIF (SA); 2) OLIF with a 2-screw lateral plate; 3) OLIF with a 4-screw lateral plate; 4) OLIF with OLLPS; and 5) OLIF with bilateral pedicle screw fixation (BPS). After validation of the intact model, physiologic loads were applied to the superior surface of L1 to simulate motions such as flexion, extension, left bending, right bending, left rotation, and right rotation. The evaluation indices included the L4/5 range of motion, the L4 maximum displacement, and the maximum stresses of the superior and inferior end plates, the cage, and the supplemental fixation. RESULTS During OLIF surgery, the OLLPS provided multiplanar stability similar to that provided by BPS. Compared with 2-screw lateral plate and 4-screw lateral plate, OLLPS had better biomechanical properties in terms of enhancing the instant stability of the surgical segment, reducing the stress on the superior and inferior end plates of the surgical segment, and decreasing the risk of cage subsidence. CONCLUSIONS With a minimally invasive background, the OLLPS can be used as an alternative to BPS in OLIF and it has better prospects for clinical promotions and applications.
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Affiliation(s)
- Yinge Wang
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China; Department of Orthopedics, The 922nd Hospital of Joint Logistics Support Force, Hengyang, Hunan, China
| | - Jiajia Wang
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Sha Tu
- Department of Nutrition, The 922nd Hospital of Joint Logistics Support Force, Hengyang, Hunan, China
| | - Shuang Li
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Jiangpu Yi
- 3D Printing Research Center, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Haien Zhao
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Huanhuan Qiao
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Kang Yan
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China.
| | - Bo Liao
- Department of Orthopedics, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China.
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91
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Kai W, Cheng C, Yao Q, Zhang C, Jian F, Wu H. Oblique Lumbar Interbody Fusion Using a Stand-Alone Construct for the Treatment of Adjacent-Segment Lumbar Degenerative Disease. Front Surg 2022; 9:850099. [PMID: 35433807 PMCID: PMC9010501 DOI: 10.3389/fsurg.2022.850099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Adjacent-segment disease (ASD) is common in patients undergone previous lumbar fusion. A typical revision treatment from posterior approach requires management of postoperative scar tissue and previously implanted instrumentation. An oblique lumbar interbody fusion (OLIF) approach allows surgeon to reduce the potential risk of posterior approach. This study aimed to analyze the clinical and radiographic efficacy of stand-alone OLIF for the treatment of lumbar adjacent-segment disease. Methods A total of 13 consecutive patients who underwent stand-alone OLIF for the treatment of adjacent-segment disease from December 2016 to January 2019 were reviewed. Visual analog scale (VAS) of back pain and leg pain and the Oswestry Disability Index (ODI) before surgery and at last postoperative clinic visits were obtained. Radiography, CT and MRI before and at last follow-up after surgery was evaluated in all patients. Results During the study period, 13 cases were successfully treated with stand-alone OLIF. The mean follow-up was 17.7 ± 8.3 months. The back pain VAS improved from 6.2 ± 1.0 to 2.0 ± 1.1 (P < 0.01), and the leg pain VAS improved from 7.0 ± 1.9 to 1.0 ± 0.9 (P < 0.01). ODI improved from 28.0 ± 7.5 to 10.8 ± 4.0 (P < 0.01). The disc height (DH) increased from 9 ± 2 to 12 ± 2 mm (P < 0.01), the cross-sectional area (CSA) of spinal canal increased from 85 ± 26 to 132 ± 24 mm2 (P < 0.01), the foraminal height increased from 17 ± 2 to 21 ± 3 mm (P < 0.01) and the CSA of foramen increased from 95 ± 25 to 155 ± 36 mm2 (P < 0.01). Cage subsidence was observed in 2 cases. Conclusions Stand-alone OLIF provides a safe and effective alternative way to treat ASD.
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Kim H, Chang BS, Chang SY. Pearls and Pitfalls of Oblique Lateral Interbody Fusion: A Comprehensive Narrative Review. Neurospine 2022; 19:163-176. [PMID: 35378589 PMCID: PMC8987540 DOI: 10.14245/ns.2143236.618] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/13/2022] [Indexed: 12/12/2022] Open
Abstract
Lumbar degenerative disease is a common problem in an aging society. Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical (MIS) technique that utilizes a retroperitoneal antepsoas corridor to treat lumbar degenerative disease. OLIF has theoretical advantages over other lumbar fusion techniques, such as a lower risk of lumbar plexus injury than direct lateral interbody fusion (DLIF). Previous studies have reported favorable clinical and radiological outcomes of OLIF in various lumbar degenerative diseases. The use of OLIF is increasing, and evidence on OLIF is growing in the literature. The indications for OLIF are also expanding with the help of recent technical developments, including stereotactic navigation systems and robotics. In this review, we present current evidence on OLIF for the treatment of lumbar degenerative disease, focusing on the expansion of surgical indications and recent advancements in the OLIF procedure.
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Affiliation(s)
- Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
- Corresponding Author Sam Yeol Chang https://orcid.org/0000-0003-4152-687X Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul 03080, Korea
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Takami M, Tsutsui S, Yukawa Y, Hashizume H, Minamide A, Iwasaki H, Nagata K, Taiji R, Schoenfeld AJ, Simpson AK, Yamada H. Lateral interbody release for fused vertebrae via transpsoas approach in adult spinal deformity surgery: a preliminary report of radiographic and clinical outcomes. BMC Musculoskelet Disord 2022; 23:245. [PMID: 35287645 PMCID: PMC8922844 DOI: 10.1186/s12891-022-05204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lateral interbody release (LIR) via a transpsoas lateral approach is a surgical strategy to address degenerative lumbar scoliosis (DLS) patients with anterior autofusion of vertebral segments. This study aimed to characterize the clinical and radiographic outcomes of this lumbar reconstruction strategy using LIR to achieve anterior column correction. METHODS Data for 21 fused vertebrae in 17 consecutive patients who underwent LIR between January 2014 and March 2020 were reviewed. Demographic and intraoperative data were recorded. Radiographic parameters were assessed preoperatively and at final follow-up, including segmental lordotic angle (SLA), segmental coronal angle (SCA), bone union rate, pelvic incidence (PI), lumbar lordosis (LL), pelvic tilt, sacral slope, PI-LL mismatch, sagittal vertical axis, Cobb angle, and deviation of the C7 plumb line from the central sacral vertical line. Clinical outcomes were evaluated using Oswestry Disability Index (ODI), visual analog scale (VAS) scores for low back and leg pain, and the short form 36 health survey questionnaire (SF-36) postoperatively and at final follow-up. Complications were also assessed. RESULTS Mean patient age was 70.3 ± 4.8 years and all patients were female. Average follow-up period was 28.4 ± 15.3 months. Average procedural time to perform LIR was 21.3 ± 9.7 min and was not significantly different from traditional lateral interbody fusion at other levels. Blood loss per single segment during LIR was 38.7 ± 53.2 mL. Fusion rate was 100.0% in this cohort. SLA improved significantly from - 7.6 ± 9.2 degrees preoperatively to 7.0 ± 8.8 degrees at final observation and SCA improved significantly from 19.1 ± 7.8 degrees preoperatively to 8.7 ± 5.9 degrees at final observation (P < 0.0001, and < 0.0001, respectively). All spinopelvic and coronal parameters, as well as ODI and VAS, improved significantly. Incidence of peri- and postoperative complications such as iliopsoas muscle weakness and leg numbness in patients who underwent LIR was as much as XLIF. Incidence of postoperative mechanical failure following LIR was also similar to XLIF. Reoperation rate was 11.8%. However, there were no reoperations associated with LIR segments. CONCLUSIONS The LIR technique for anterior column realignment of fused vertebrae in the context of severe ASD may be an option of a safe and effective surgical strategy.
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Affiliation(s)
- Masanari Takami
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
| | - Shunji Tsutsui
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Yasutsugu Yukawa
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroshi Hashizume
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Akihito Minamide
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroshi Iwasaki
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Keiji Nagata
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Ryo Taiji
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Li J, Sun Y, Guo L, Zhang F, Ding W, Zhang W. Efficacy and safety of a modified lateral lumbar interbody fusion in L4-5 lumbar degenerative diseases compared with traditional XLIF and OLIF: a retrospective cohort study of 156 cases. BMC Musculoskelet Disord 2022; 23:217. [PMID: 35255886 PMCID: PMC8903737 DOI: 10.1186/s12891-022-05138-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The authors designed a modified lateral lumbar interbody fusion (LLIF) procedure named as XOLIF and compared the efficacy and safety with traditional LLIF procedures. METHODS Patients were divided into XLIF, OLIF, and XOLIF group according to the surgical approach. Cases of psoas major and vascular space stenosis, psoas major muscle elevation, psoas major muscle hypertrophy, and high iliac crest were recorded. Basic information, composition ratio of specific cases, Visual analog scale (VAS), Oswestry Disability Index (ODI), interbody fusion rate and complications were compared between the 3 groups. RESULTS The study included 156 cases of L4-5 LLIF. There was no statistical difference in age, gender, BMI among the three groups. Cases with stenosis between psoas muscle and artery accounted for 11.8 and 18.4% of the XLIF and XOLIF group, respectively, while no case of this type had undergone OLIF surgery, the difference was statistically significant (P < 0.05). The proportions of high iliac crest cases in the OLIF and XOLIF group were 12.5 and 18.4%, respectively, while the XLIF group with vertical approach is not suitable for cases with high iliac crest. The postoperative VAS and ODI of the three groups were significantly improved compared with those before operation. There were 51 cases (32.7%) of complications including 21cases in XLIF group, 20 cases in OLIF Group and 10 cases in XOLIF group. XOLIF group has more advantages in reducing lumbar plexus injury and the risk of vascular injury. CONCLUSIONS XOLIF showed good clinical efficacy and technical advantages with a low incidence of intraoperative and postoperative complications, especially in the specific cases.
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Affiliation(s)
- Jiaqi Li
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China
| | - Yapeng Sun
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China
| | - Lei Guo
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China
| | - Fei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China
| | - Wenyuan Ding
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China
| | - Wei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei Province, China.
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95
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Zhao L, Xie T, Wang X, Yang Z, Pu X, Lu Y, Zeng J. Clinical and radiological evaluation of cage subsidence following oblique lumbar interbody fusion combined with anterolateral fixation. BMC Musculoskelet Disord 2022; 23:214. [PMID: 35248042 PMCID: PMC8898418 DOI: 10.1186/s12891-022-05165-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cage subsidence (CS) was previously reported as one of the most common complications following oblique lumbar interbody fusion (OLIF). We aimed to assess the impacts of CS on surgical results following OLIF combined with anterolateral fixation, and determine its radiological characteristics as well as related risk factors.
Methods
Two hundred and forty-two patients who underwent OLIF at L4-5 and with a minimum 12 months follow-up were reviewed. Patients were divided into three groups according to the extent of disk height (DH) decrease during follow-up: no CS (DH decrease ≤ 2 mm), mild CS (2 mm < DH decrease ≤ 4 mm) and severe CS (DH decrease > 4 mm). The clinical and radiological results were compared between groups to evaluate radiological features, clinical effects and risk factors of CS.
Results
CS was identified in 79 (32.6%) patients, including 48 (19.8%) with mild CS and 31 (11.8%) with severe CS. CS was mainly identified within 1 month postoperatively, it did not progress after 3 months postoperatively, and more noted in the caudal endplate (44, 55.7%). In terms of clinical results, patients in the mild CS group were significantly worse than those in the no CS group, and patients in the severe CS group were significantly worse than those in the mild CS group. There was no significant difference in fusion rate between no CS (92.6%, 151/163) and mild CS (83.3%, 40/48) groups. However, significant lower fusion rate was observed in severe CS group (64.5%, 20/31) compared to no CS group. CS related risk factors included osteoporosis (OR = 5.976), DH overdistraction (OR = 1.175), flat disk space (OR = 3.309) and endplate injury (OR = 6.135).
Conclusion
CS following OLIF was an early postoperative complication. Higher magnitudes of CS were associated with worse clinical improvements and lower intervertebral fusion. Osteoporosis and endplate injury were significant risk factors for CS. Additionally, flat disk space and DH over-distraction were also correlated with an increased probability of CS.
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96
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Oblique lateral interbody fusion combined with different internal fixations for the treatment of degenerative lumbar spine disease: a finite element analysis. BMC Musculoskelet Disord 2022; 23:206. [PMID: 35246101 PMCID: PMC8897936 DOI: 10.1186/s12891-022-05150-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background Little is known about the biomechanical performance of different internal fixations in oblique lumbar interbody fusion (OLIF). Here, finite element (FE) analysis was used to describe the biomechanics of various internal fixations and compare and explore the stability of each fixation. Methods CT scans of a patient with lumbar degenerative disease were performed, and the l3-S1 model was constructed using relevant software. The other five FE models were constructed by simulating the model operation and adding different related implants, including (1) an intact model, (2) a stand-alone (SA) model with no instrument, (3) a unilateral pedicle screw model (UPS), (4) a unilateral pedicle screw contralateral translaminar facet screw model (UPS-CTFS), (5) a bilateral pedicle screw (BPS) model, and (6) a cortical bone trajectory screw model (CBT). Various motion loads were set by FE software to simulate lumbar vertebral activity. The software was also used to extract the range of motion (ROM) of the surgical segment, CAGE and fixation stress in the different models. Results The SA group had the greatest ROM and CAGE stress. The ROM of the BPS and UPS-CTFS was not significantly different among motion loadings. Compared with the other three models, the BPS model had lower internal fixation stress among loading conditions, and the CBT screw internal fixation had the highest stress among loads. Conclusions The BPS model provided the best biomechanical stability for OLIF. The SA model was relatively less stable. The UPS-CTFS group had reduced ROM in the fusion segments, but the stresses on the internal fixation and CAGE were relatively higher in the than in the BPS group; the CBT group had a lower flexion and extension ROM and higher rotation and lateral flexion ROM than the BPS group. The stability of the CBT group was poorer than that of the BPS and LPS-CTFS groups. The CAGE and internal fixation stress was greater in the CBT group.
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97
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Hiyama A, Sakai D, Katoh H, Nomura S, Sato M, Watanabe M. Comparative Study of Cage Subsidence in Single-Level Lateral Lumbar Interbody Fusion. J Clin Med 2022; 11:jcm11051374. [PMID: 35268465 PMCID: PMC8911078 DOI: 10.3390/jcm11051374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022] Open
Abstract
We investigated the incidence and clinical features of cage subsidence after single-level lateral lumbar interbody fusion (LLIF). We studied a retrospective cohort of 59 patients (34 males, 25 females; mean age, 68.9 years) who received single-level LLIF. Patients were classified into subsidence and no-subsidence groups. Cage subsidence was defined as any violation of either endplate, classified using radiographs and computed tomography (CT) images. After one year, we compared patient characteristics, surgical parameters, radiological findings, pain scores, and fusion status. We also compared the Hounsfield unit (HU) endplate value obtained on CT preoperatively. Twenty patients (33.9%) had radiographic evidence of interbody cage subsidence. There were significant differences between the subsidence and no-subsidence groups in sex, cage height, fusion rate, and average HU value of both endplates (p < 0.05). There were no significant differences in age, height, weight, or body mass index. Moreover, there were no significant differences in global alignment and Numerical Rating Scale change in low back pain, leg pain, and numbness. Despite suggestions that patients with lower HU values might develop cage subsidence, our results showed that cage subsidence after single-level LLIF was not associated with low back pain, leg pain, or numbness one year post-operation.
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98
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Li XH, She LJ, Zhang W, Cheng XD, Fan JP. Biomechanics of extreme lateral interbody fusion with different internal fixation methods: a finite element analysis. BMC Musculoskelet Disord 2022; 23:134. [PMID: 35139843 PMCID: PMC8829978 DOI: 10.1186/s12891-022-05049-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/20/2022] [Indexed: 01/03/2023] Open
Abstract
Background Establishing a normal L3–5 model and using finite element analysis to explore the biomechanical characteristics of extreme lateral interbody fusion (XLIF) with different internal fixation methods. Method The L3–5 CT image data of a healthy adult male volunteer were selected to establish a normal lumbar finite element model (M0). The range of motion (ROM) of L3–4 and L4–5, under flexion, extension, left bending, right bending, left rotation, and right rotation, together with L3–4 disc pressure was analyzed. Then the L4–5 intervertebral disc was excised and implanted with a cage, supplemented by different types of internal fixation, including lateral two-hole plate model (M1), lateral four-hole plate model (M2), VerteBRIDGE plating model (M3), lateral pedicle model (M4), posterior unilateral pedicle screw model (M5) and posterior bilateral pedicle screw model (M6). The ROM,the maximum stress value of the cage, and the maximum stress value of the intervertebral disc of L3–4 were analyzed and studied . Results The ROM of L3–4 and L4-L5 segments in the validation model under various motion states was basically consistent with previous reports. The lumbar finite element model was validated effectively. After XLIF-assisted internal fixation, the range of activity in L3–4 segments of each internal fixation model was greater than that of the normal model under various working conditions, among which the M5、M6 model had the larger range of activity in flexion and extension. After the internal fixation of L4–5 segments, the mobility in M1-M6 was significantly reduced under various motion patterns. In terms of flexion and extension, the posterior pedicle fixation model (M5、M6) showed a significant reduction,followed by M2. The maximal von mises cage stress of M1 was obviously greater than that of other models (except the left bending). Compared with M0, the intervertebral disc stress of M1-M6 at L3–4 segments was increased. Conclusions It is recommended that the posterior bilateral pedicle screw model is the first choice, followed by the lateral four-hole plate model for fixation during XLIF surgery. However, it is still necessary to be aware of the occurrence of adjacent segment degeneration (ASD) in the later stage.
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Affiliation(s)
- Xiao-Hua Li
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Li-Jun She
- Department of Tuberculosis, The Fifth Hospital of Shijiazhuang, No.42 Tanan Road, Shijiazhuang, 050000, China
| | - Wei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China. .,Department of Spinal Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China.
| | - Xiao-Dong Cheng
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Jin-Peng Fan
- Department of Orthopedic Surgery, Shijiazhuang First Hospital, No. 365 Jianhua South Street, Shijiazhuang, 050000, China
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Guha D, Mushlin HM, Muthiah N, Vodovotz LL, Agarwal N, Alan N, Hamilton DK, Okonkwo DO, Kanter AS. CT Hounsfield Units as a predictor of reoperation and graft subsidence following standalone and multi-level lateral lumbar interbody fusion. World Neurosurg 2022; 161:e417-e426. [PMID: 35149250 DOI: 10.1016/j.wneu.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Standalone single and multi-level lateral lumbar interbody fusion (LLIF) are increasingly being applied to treat degenerative spinal conditions in a less invasive fashion. Graft subsidence following LLIF is a known complication and has been associated with poor bone mineral density (BMD). Previous research has demonstrated the utility of CT Hounsfield Units (HU) as a surrogate for BMD. This study aims to investigate the relationship between CT HU and subsidence and reoperation after standalone and multi-level LLIF. METHODS A prospectively-maintained single-institution database was retrospectively reviewed for LLIF patients from 2017-2020 including single and multi-level standalone cases with or without supplemental posterior fixation. Data on demographics, graft parameters, BMD on DEXA, preoperative mean segmental CT HU, and postoperative subsidence and reoperation, were collected. Three-foot standing radiographs were used to measure preoperative global sagittal alignment and disc height, and subsidence at last follow-up. Subsidence was classified using the Marchi grading system corresponding to disc height loss: Grade 0: 0-24%; I: 25-49%; II: 50-74%; III: 75-100%. RESULTS Eighty-nine LLIF patients met study criteria, with mean follow-up 19.9 ± 13.9 months. Among the 54 patients who underwent single-level LLIF, mean segmental HU was 152.0 ± 8.7 in 39 patients with Grade 0 subsidence, 136.7 ± 10.4 in nine with Grade I subsidence, 133.9 ± 23.1 in three with Grade II subsidence, and 119.9 ± 30.9 in three with Grade III subsidence (p=0.032). In the 96 instrumented levels in 35 patients who underwent multi-level LLIF, 85 had Grade 0 subsidence, 9 Grade I, 1 Grade II, and 1 Grade III, with no differences in HU. In multivariate logistic regression, increased CT HU was independently associated with a decreased risk of reoperation in both single-level and multi-level LLIF (OR:0.98, 95%CI:0.97-0.99, p=0.044; and OR:0.97, 95%CI: 0.94-0.99, p=0.017, respectively). Overall BMD on DEXA was not associated with graft subsidence nor reoperation. Using a receiver-operating-characteristic curve to establish separation between patients requiring reoperation and those that did not, the determined threshold HU for single-level LLIF was 131.4 (sensitivity 0.62, specificity 0.65), and for multi-level was 131.0 (sensitivity 0.67, specificity 0.63). CONCLUSIONS Lower CT HU are independently associated with an increased risk of graft subsidence following single-level LLIF. In addition, lower CT HU significantly increased the risk of reoperation in both single and multi-level LLIF with a critical threshold of 131 HU. Preoperative CT HU may provide a more robust gauge of local bone quality and the likelihood of graft subsidence requiring reoperation following LLIF, than overall BMD.
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Affiliation(s)
- Daipayan Guha
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Harry M Mushlin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nallammai Muthiah
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lena L Vodovotz
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Poor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated with Intraoperative Endplate Injuries and Late-onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review. Clin Orthop Relat Res 2022; 480:163-188. [PMID: 34324459 PMCID: PMC8673985 DOI: 10.1097/corr.0000000000001915] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/06/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND A major complication of lateral lumbar interbody fusion (LLIF) is cage subsidence, which may lead to clinical problems, including loss of disc height correction, altered spinal alignment, recurrent pain, and vertebral body fracture. A thorough review of the current knowledge about the risk factors for the two types of cage subsidence after LLIF-intraoperative endplate injury and late-onset cage subsidence-could bring attention to well-established risk factors for clinical consideration while identifying any incompletely characterized factors that require further research to clarify. QUESTIONS/PURPOSES We performed a systematic review to answer the following questions: (1) Are bone quality and surrogates for bone quality, such as patient age and sex, associated with an increased likelihood of cage subsidence? (2) Are implant-related factors associated with an increased likelihood of cage subsidence? METHODS Two independent reviewers comprehensively searched Medline, Embase, Cochrane Library, PubMed, and Web of Science from 1997 to 2020 to identify all potential risk factors for cage subsidence after LLIF. Discrepancies were settled through discussion during full-text screening. Search terms included "lateral" AND "interbody fusion" AND "subsidence" OR "settling" OR "endplate injury" OR "endplate violation" WITHOUT "cervical" OR "transforaminal" OR "biomechanical." Eligible studies were retrospective or prospective comparative studies, randomized controlled trials, and case series with sample sizes of 10 patients or more reporting risk factors for cage subsidence or endplate injury after LLIF. Studies that involved cervical interbody fusions and biomechanical and cadaveric experiments were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the studies' quality of evidence. The initial database review found 400 articles. Thirty-four articles with moderate- to very-low-quality evidence met the inclusion criteria for analysis. A total of 3233 patients (58% [1860] of whom were female) were included in this review. Two types of cage subsidence were reviewed: late-onset cage subsidence, which occurs gradually postoperatively, and intraoperative endplate injury, which is derived from iatrogenic endplate violation during endplate preparation or cage insertion. Among 20 studies with moderate quality of evidence according to the GRADE criteria, eight studies reported risk factors for cage subsidence related to bone mineral density and its surrogates and 12 studies focused on risk factors regarding implant factors, including cage dimension, cage material, construct length, and supplementary instrumentation. RESULTS Patients with a dual x-ray absorptiometry T-score of -1.0 or less, age older than 65 years, and female sex were considered to have a high risk of both types of cage subsidence. Regarding cage size, cage width ≥ 22 mm helped to avoid late-onset cage subsidence, and cage height ≤ 11 mm was recommended by some studies to avoid intraoperative endplate injuries. Studies recommended that multilevel LLIF should be conducted with extra caution because of a high risk of losing the effect of indirect decompression. Studies found that standalone LLIF might be sufficient for patients without osteoporosis or obesity, and supplementary instrumentation should be considered to maintain the postoperative disc height and prevent subsidence progression in patients with multiple risk factors. The effect of the bone graft, cage material, endplate condition, and supplementary instrumentation on cage subsidence remained vague or controversial. CONCLUSION Patients with poor bone density, patients who are older than 65 years, and female patients should be counseled about their high risk of developing cage subsidence. Surgeons should avoid narrow cages when performing LLIF to minimize the risk of late-onset cage subsidence, while being cautious of an aggressive attempt to restore disc height with a tall cage as it may lead to intraoperative endplate injury. For multilevel constructs, direct decompression approaches, such as posterior and transforaminal LIF, should be considered before LLIF, since the effect of indirect decompression may be difficult to maintain in multilevel LLIF because of high risks of cage subsidence. The effect of the cage material and supplementary instrumentation require stronger evidence from prospectively designed studies with larger sample size that randomly assign patients to polyetheretherketone (PEEK) or titanium cages and different fixation types. Future research on intraoperative endplate injuries should focus on the specific timing of when endplate violation occurs with the help of intraoperative imaging so that attempts can be made to minimize its occurrence. LEVEL OF EVIDENCE Level IV, therapeutic study.
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