ALIF- und PLIF-Interposition bei low-grade isthmischen Spondylolisthesen L5/S1: Langzeitvergleich der interkorporellen Fusionstechnik (ALIF – PLIF)

Comparison of ALIF and PLIF in Isthmic Lumbosacral Spondylolisthesis. A Multicenter Surveillance Study of 602 cases from the German Spine Registry (DWG Register)

BACKGROUND

 Isthmic spondylolisthesis most commonly occurs in the lumbosacral junction and can cause backpain and radicular pain as well as stiffness with progressive immobilization, with a negative impact on an individual's ability to work and quality of life. Multiple operative treatments are currently available. This study aims to compare complications, demography, and clinical features between anterior lumbar interbody fusion (ALIF) and posterior lumber body fusion (PLIF) in the operative treatment in isthmic spondylolisthesis.

METHODS

 An analysis of data from the German spine registry (Deutsche Wirbelsäulengesellschaft [DWG]-Register) of patients who underwent operative treatment (PLIF and ALIF) for isthmic spondylolisthesis in the sacrolumbar junction in 170 departments between January 2017 and May 2021 was performed. Age, gender, American Society of Anesthesiologists (ASA) score, surgical approach, smoker/nonsmoker, as well as severeness of the spondylolisthesis according to the Meyerding classification were evaluated.

RESULTS

 In total, 602 patients undergoing fusion in L5/S1 were identified in the registry, n = 570 PLIF (group 1) and n = 32 ALIF (group 2). A significant difference in the ASA score between the two groups was noted; group 1 had more patients suffering a more debilitating disease in comparison to group 2. There was no significant difference in gender, grade of spondylolisthesis, age, or smoking status. Significant differences were found in operative and postoperative variables and complications (fusion material, dura injury).

CONCLUSION

 No difference was found between the two procedures in terms of symptomatic benefit of patients who underwent either ALIF or PLIF. According to the DWG Register, PLIF was the preferred method to treat isthmic spondylolisthesis in the sacrolumbar junction in Germany. To compare these two spine fusion techniques, further studies with an adequate sample size and follow-up period are required.

Exploration of the Extraperitoneal Approach for Single-Level Anterior Lumbar Interbody Fusion: Imaging, Anatomical and Clinical Research

Background

To explore extraperitoneal approach as an optimal option for reducing peritoneal disruption at a single-level disc in anterior lumbar interbody fusion (ALIF).

Methods

First, abdominal axial CT images obtained from 111 patients were observed to evaluate the distribution of extraperitoneal fat at L2-S1 and measure the lateral distances between the midline and the lateral borders of the rectus and the extraperitoneal fat for each disc level. Second, eight embalmed corpses were dissected along the lateral border of the rectus to expose the peritoneum, which was then separated laterally and medially to evaluate the distribution of fat and peritoneum adhesion. Finally, a total of 58 patients were selected for ALIF. For L2-L4 discs and L4-S1, the pararectus approach and the paramedian approach were utilized, respectively.

Results

Extraperitoneal fat was observed behind the rectus at the L5-S1 and the lateral distance between the fat and midline and the lateral border of the rectus gradually decreased on both sides of L2-5. On the cranial side of the arcuate line, it was easier to separate the peritoneum outward along the lateral edge of the rectus. When bluntly dissected medially, the peritoneum was closely adhered to abdominal wall. No complications such as peritoneal damage, retroperitoneal hematoma and neurological complications occurred in 58 patients undergoing the aforementioned surgical methods.

Conclusions

For L4-S1, the paramedian approach is the optimal technique to expose the disc, whereas the pararectus approach is the feasible surgical method at L2-4.

Comparison of 90-day complications and two-year reoperation rates between anterior and posterior interbody fusion for single-level degenerative spondylolisthesis

Background

For the surgical treatment of single-level degenerative spondylolisthesis (DS), patients can be treated with either an anterior or posterior interbody fusion. Prior studies have shown that patients with symptomatic degenerative spondylolisthesis treated surgically maintain substantially greater pain relief and improvement in function when compared to those treated non-operatively, but no consensus has emerged between which approach results in the best outcomes.

Methods

The PearlDiver MARINER database was queried for patients with single-level DS who underwent either an anterior or posterior lumbar interbody fusion. Both populations were compared on multiple outcomes, including reoperation, post-operative complications, and readmission rates at 90 days, as well as rates of reoperation and cauda equina syndrome two-years postoperatively.

Results

At 90 days patients who underwent anterior interbody were found to have higher rates of DVT (OR 2.53, 95% CI 1.74 – 3.70, p<0.001), ileus (OR 1.43, 95% CI 1.25 – 1.64, p<0.001), and readmission (OR 1.28, 95% CI 1.19 – 1.38, p<0.001). Patients who underwent posterior interbody fusion were found to have higher rates of revision procedures (OR 0.63, 95% CI 0.59 – 0.66, p<0.001), transfusion (OR 0.68, 95% CI 0.58 – 0.78, p<0.001), acute kidney injury (OR 0.84, 95% CI 0.75 – 0.95, p=0.0046), and cauda equina syndrome (OR 0.53, 95% CI 0.40 – 0.69, p<0.001). At 2 years, patients who underwent posterior fusion required revision procedures (OR 0.70, 95% CI 0.67 – 0.74, p<0.001) and developed cauda equina syndrome (OR 0.62, 95% CI 0.50 – 0.77, p<0.001) at a higher rate than those who underwent anterior fusion.

Conclusions

Patients who underwent anterior interbody fusion for treatment of degenerative spondylolisthesis were found to have increased rates of DVT, ileus, and were more likely to be readmitted to the hospital within 90 days, while patients who underwent posterior interbody fusion were found to have higher rates of reoperation, transfusion, AKI, and cauda equina syndrome. Increased rates of reoperation and development of cauda equina in the posterior fusion group persisted at 2 years post-operatively.

Safety and efficacy of stand-alone anterior lumbar interbody fusion in low-grade L5-S1 isthmic spondylolisthesis

Introduction

Surgical management of isthmic spondylolisthesis is controversial and reports on anterior approaches in the literature are scarce.

Research question

To evaluate the safety and efficacy of stand-alone anterior lumbar interbody fusion (ALIF) in patients with symptomatic low-grade L5-S1 isthmic spondylolisthesis.

Material and methods

All adult patients with isthmic spondylolisthesis of the lumbosacral junction treated in a single institution between 2008 and 2019 with stand-alone ALIF were screened. A titan cage was inserted at L5-S1 with vertebral anchoring screws. Prospectively collected surgical, clinical and radiographic data were analyzed retrospectively.

Results

34 patients (19 men, 15 women, mean age 52.5 ​± ​11.5 years) with a mean follow-up of 3.2 (±2.5) years were analyzed. 91.2% (n ​= ​31) of patients had a low-grade spondylolisthesis and 8.8% (n ​= ​3) grade III according to Meyerding classification. Mean COMI and ODI scores improved significantly from 6.9 (±1.5) and 35.5 (±13.0) to 2.0 (±2.5) and 10.2 (±13.0), respectively after one year, and to 1.7 (±2.5) and 8.2 (±9.6), respectively, after two years. The COMI and ODI scores improved in 86.4% and 80%, respectively, after one year and 92.9% of patients after two years by at least the minimal clinically important difference. No intraoperative complications were recorded. 8.8% (n ​= ​3) of patients needed a reoperation.

Discussion and conclusion

After stand-alone ALIF for symptomatic isthmic spondylolisthesis, the patients improved clinically important after one and two years. Stand-alone ALIF is a safe and effective surgical treatment option for low-grade isthmic spondylolisthesis.

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Report of a series of patients with symptomatic low-grade L5-S1 isthmic spondylolisthesis treated by stand-alone ALIF.

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Patient reported outcomes showed clinically important improvements after one and two years.

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Stand-alone ALIF proved to be a safe and effective technique to treat symptomatic low-grade L5-S1 isthmic spondylolisthesis.

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There were no vascular or other major complications.

Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion versus Anterior Lumbar Interbody Fusion with Posterior Instrumentation at L5/S1

OBJECTIVE

To compare outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) at L5/S1.

METHODS

Primary, elective, single, MIS-TLIF, or ALIF with posterior fixation at L5/S1 were identified. Patient-reported outcome measures (PROMs) were collected. Coarsened exact matching was used to control for significant differences. Achievement of minimum clinically important difference [MCID] was determined by comparing ΔPROM scores with threshold values. Demographic/perioperative characteristics were compared between MIS-TLIF and ALIF cohorts using χ² Student t tests. Differences in mean PROM scores, MCID rates, and postoperative complications were evaluated using an unpaired t test.

RESULTS

After coarsened exact matching, 93 patients received MIS-TLIF and 50 received ALIF. Cohorts differed in operative time, estimated blood loss, and postoperative narcotic consumption on postoperative day 0 (P < 0.034, all). Mean PROMs differed significantly on 12-Item Short-Form Physical Component Summary at 6 weeks and 1 year, Patient-Reported Outcomes Measurement Information System Physical Function at 6 weeks, Oswestry Disability Index at 6 weeks, and visual analog scale (VAS) back at 6 weeks, with the ALIF cohort showing significantly improved mean PROMs (P ≤ 0.044, all). Significantly greater rates were reported of MCID achievement for PROMs for the ALIF cohort: VAS back at 6 weeks, Oswestry Disability Index at 12 weeks, 12-Item Short-Form Physical Component Summary at 6 weeks, and Patient-Reported Outcomes Measurement Information System Physical Function at 12 weeks (P ≤ 0.047, all). A greater rate of MCID achievement for the MIS-TLIF cohort was seen for 6-week and overall VAS leg (P < 0.046, all). Postoperative fever was greater in the TLIF cohort (9.6% vs. 2.0%; P < 0.047).

CONCLUSIONS

Patients undergoing ALIF showed significantly improved rates of MCID achievement for disability, physical function, and back pain during the early postoperative period. However, the overall MCID achievement rate for leg pain was higher for the MIS-TLIF cohort.

Comparison of Different Approaches in Lumbosacral Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007–2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.

Technique for Exposing Lumbar Discs in Anterior Approach Using Steinmann Wires: Arthroplasties or Arthrodesis

BACKGROUND

Due to increasing longevity, the incidence of degenerative lumbar disc diseases has increased, and surgical treatment is often necessary. In this context, the anterior approach becomes an important technique. However, one of the main limitations of this method is the need for dedicated retractors, which requires larger incisions for its positioning and increases the cost of the procedure. The objective of the present study was to describe a technique for retracting abdominal structures by anterior approaches to the lumbar spine using Steinmann wires.

METHODS

This manuscript consists of a technique description of anterior approach for lumbar spine.

RESULTS

Surgical treatment of degenerative lumbar spine disease is often necessary when the patients have symptoms refractory to conservative treatments. Many of them will be candidates for surgical treatment with anterior approach, either for arthrodesis/anterior lumbar interbody fusion or arthroplasty. Small incisions are performed for positioning the modified Langenbeck retractors and the Steinmann wires. These retractors are easily positioned and provide good exposure of the lumbar discs making it possible to implant appropriate cages for restoring the necessary height, lordosis, and sagittal balance.

CONCLUSIONS

The technique described is safe, inexpensive, and reproducible. Simple and easily accessible instruments are required in most hospital complexes.