1
|
Filley A, Baldwin A, Ben-Natan AR, Hansen K, Arora A, Xiao A, Hammond D, Chen C, Tweedt I, Rohde J, Link T, Berven S, Sawyer A. The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100327. [PMID: 38962714 PMCID: PMC11219986 DOI: 10.1016/j.xnsj.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 07/05/2024]
Abstract
Background Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes. Methods PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation. Results A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed. Conclusions Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.
Collapse
Affiliation(s)
- Anna Filley
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Avionna Baldwin
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Keith Hansen
- Department of General Surgery, University of California, San Francisco, CA, USA
| | - Ayush Arora
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Angel Xiao
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Deana Hammond
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Caressa Chen
- Loyola University Medical Center; Maywood IL, USA
| | - Isobel Tweedt
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, USA
| | - James Rohde
- Department of Integrative Biology, University of California Berkeley, USA
| | - Thomas Link
- Department of Radiology and Biomedical Imagery, University of California, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Aenor Sawyer
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| |
Collapse
|
2
|
Calek AK, Cornaz F, Suter M, Fasser MR, Farshad M, Widmer J. Endplate weakening during cage bed preparation significantly reduces endplate load capacity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08289-4. [PMID: 38733400 DOI: 10.1007/s00586-024-08289-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE To analyze the effect of endplate weakness prior to PLIF or TLIF cage implantation and compare it to the opposite intact endplate of the same vertebral body. In addition, the influence of bone quality on endplate resistance was investigated. METHODS Twenty-two human lumbar vertebrae were tested in a ramp-to-failure test. One endplate of each vertebral body was tested intact and the other after weakening with a rasp (over an area of 200 mm2). Either a TLIF or PLIF cage was then placed and the compression load was applied across the cage until failure of the endplate. Failure was defined as the first local maximum of the force measurement. Bone quality was assessed by determining the Hounsfield units (HU) on CT images. RESULTS With an intact endplate and a TLIF cage, the median force to failure was 1276.3N (693.1-1980.6N). Endplate weakening reduced axial endplate resistance to failure by 15% (0-23%). With an intact endplate and a PLIF cage, the median force to failure was 1057.2N (701.2-1735.5N). Endplate weakening reduced axial endplate resistance to failure by 36.6% (7-47.9%). Bone quality correlated linearly with the force at which endplate failure occurred. Intact and weakened endplates showed a strong positive correlation: intact-TLIF: r = 0.964, slope of the regression line (slope) = 11.8, p < 0.001; intact-PLIF: r = 0.909, slope = 11.2, p = 5.5E-05; weakened-TLIF: r = 0.973, slope = 12.5, p < 0.001; weakened-PLIF: r = 0.836, slope = 6, p = 0.003. CONCLUSION Weakening of the endplate during cage bed preparation significantly reduces the resistance of the endplate to subsidence to failure: endplate load capacity is reduced by 15% with TLIF and 37% with PLIF. Bone quality correlates with the force at which endplate failure occurs.
Collapse
Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mauro Suter
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
3
|
Calek AK, Cornaz F, Suter M, Fasser MR, Baumgartner S, Sager P, Farshad M, Widmer J. Load distribution on intervertebral cages with and without posterior instrumentation. Spine J 2024; 24:889-898. [PMID: 37924848 DOI: 10.1016/j.spinee.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/18/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND CONTEXT Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) are well-established procedures for spinal fusion. However, little is known about load sharing between cage, dorsal construct, and biological tissue within the instrumented lumbar spine. PURPOSE The aim of this study was to quantify the forces acting on cages under axial compression force with and without posterior instrumentation. STUDY DESIGN Biomechanical cadaveric study. METHODS Ten lumbar spinal segments were tested under uniaxial compression using load cell instrumented intervertebral cages. The force was increased in 100N increments to 1000N or a force greater than 500N on one load cell. Each specimen was tested after unilateral PLIF (uPLIF), bilateral PLIF (bPLIF) and TLIF each with/without posterior instrumentation. Dorsal instrumentation was performed with 55N of compression per side. RESULTS Cage insertion resulted in median cage preloads of 16N, 29N and 35N for uPLIF, bPLIF, and TLIF. The addition of compressed dorsal instrumentation increased the median preload to 224N, 328N, and 317N, respectively. With posterior instrumentation, the percentage of the external load acting on the intervertebral cage was less than 25% at 100N (uPLIF: 14.2%; bPLIF: 16%; TLIF: 11%), less than 45% at 500N (uPLIF: 31.8%; bPLIF: 41.1%; TLIF: 37.9%) and less than 50% at 1000N (uPLIF: 40.3%; bPLIF: 49.7%; TLIF: 43.4%). Without posterior instrumentation, the percentage of external load on the cages was significantly higher with values above 50% at 100N (uPLIF: 55.6%; bPLIF: 75.5%; TLIF: 66.8%), 500N (uPLIF: 71.7%; bPLIF: 79.2%; TLIF: 65.4%), and 1000N external load (uPLIF: 73%; bPLIF: 80.5%; TLIF: 66.1%). For absolute loads, preloads and external loads must be added together. CONCLUSIONS Without posterior instrumentation, the intervertebral cages absorb more than 50% of the axial load and the load distribution is largely independent of the loading amplitude. With posterior instrumentation, the external load acting on the cages is significantly lower and the load distribution becomes load amplitude dependent, with a higher proportion of the load transferred by the cages at high loads. The bPLIF cages tend to absorb more force than the other two cage configurations. CLINICAL SIGNIFICANCE Cage instrumentation allows some of the compression force to be transmitted through the cage to the screws below, better distributing and reducing the overall force on the pedicle screws at the end of the construct and on the rods.
Collapse
Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland
| | - Mauro Suter
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sina Baumgartner
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Sager
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland; University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| |
Collapse
|
4
|
Zhou Y, Zhou C, Li Q, Cai L, Kou B, Fang W, Yao Z, Wei M, Zhang S, Liu W. Efficacy of PE-PLIF with a novel ULBD approach for lumbar degeneration diseases: a large-channel endoscopic retrospective study. J Orthop Surg Res 2024; 19:269. [PMID: 38685055 PMCID: PMC11057128 DOI: 10.1186/s13018-024-04755-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE This study aims to assess the effectiveness of Percutaneous Endoscopic Posterior Lumbar Interbody Fusion (PE-PLIF) combined with a novel Unilateral Laminotomy for Bilateral Decompression (ULBD) approach using a large-channel endoscope in treating Lumbar Degenerative Diseases (LDD). METHODS This retrospective analysis evaluates 41 LDD patients treated with PE-PLIF and ULBD from January 2021 to June 2023. A novel ULBD approach, called 'Non-touch Over-Top' technique, was utilized in this study. We compared preoperative and postoperative metrics such as demographic data, Visual Analogue Scale (VAS) for pain, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) score, surgical details, and radiographic changes. RESULTS The average follow-up duration was 14.41 ± 2.86 months. Notable improvements were observed postoperatively in VAS scores for back and leg pain (from 5.56 ± 0.20 and 6.95 ± 0.24 to 0.20 ± 0.06 and 0.12 ± 0.05), ODI (from 58.68 ± 0.80% to 8.10 ± 0.49%), and JOA scores (from 9.37 ± 0.37 to 25.07 ± 0.38). Radiographic measurements showed significant improvements in lumbar and segmental lordosis angles, disc height, and spinal canal area. A high fusion rate (97.56% at 6 months, 100% at 12 months) and a low cage subsidence rate (2.44%) were noted. CONCLUSIONS PE-PLIF combined with the novel ULBD technique via a large-channel endoscope offers significant short-term benefits for LDD management. The procedure effectively expands spinal canal volume, decompresses nerve structures, improves lumbar alignment, and stabilizes the spine. Notably, it improves patients' quality of life and minimizes complications, highlighting its potential as a promising LDD treatment option.
Collapse
Affiliation(s)
| | | | | | - Lei Cai
- Wuhan Fourth Hospital, Wuhan, China
| | | | | | - Zhi Yao
- Wuhan Fourth Hospital, Wuhan, China
| | | | | | | |
Collapse
|
5
|
Kim JE, Kim H, Park EJ, Park DK. A Comparison of 2 Cage Sizes in Biportal Endoscopic Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2024:01933606-990000000-00308. [PMID: 38650073 DOI: 10.1097/bsd.0000000000001633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 03/07/2024] [Indexed: 04/25/2024]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE This study compared the fusion and subsidence rate and clinical outcomes when using different-sized static PEEK cages in BE-TLIF. SUMMARY OF BACKGROUND DATA Biportal endoscopic techniques for transforaminal lumbar interbody fusion (BE-TLIF) have been shown to have similar clinical and fusion outcomes with faster clinical recovery in comparison to tubular surgery. Subsidence of the interbody, however, could be a complication. METHODS Patients who underwent 1 or 2 level BE-TLIF for degenerative and isthmic spondylolisthesis between January 2019 and January 2022 were included. A 32×10 mm cage (group A) and a 40×15 mm cage (group B) were compared. The visual analog scale (VAS) for back and leg symptoms, and Oswestry disability index (ODI) were collected. Plain radiographs and computed tomography assessed fusion and subsidence at a minimum of 12 months. RESULTS Of the 69 enrolled patients, 39 group A patients (51 levels) and 30 group B patients (32 levels) were compared. The operation time per level was 123 ± 15.8 and 138 ± 10.5 minutes per fusion level in groups A and B, respectively (P < 0.05). ODI improved from 64.8 ± 6.2 to 15.7 ± 7.1 in group A and from 65.3 ± 5.6 to 15.1 ± 6.3 in group B at the final follow-up (P < 0.05). VAS leg and back score improvement between the groups did not differ; however, the 3-month postoperative VAS back improvement was significantly higher in group B. The final fusion rate at the final follow-up did not significantly differ; however, the fusion ratio at 1 year was higher in group B (P < 0.05). Subsidence occurred in 5 cases (9.8%) in group A and none in group B (P < 0.05). CONCLUSION BE-TLIF using a larger cage can be performed safely with similar patient-reported outcome measures with a faster fusion rate with less subsidence risk. LEVEL OF STUDY III.
Collapse
Affiliation(s)
- Ju-Eun Kim
- Department of Orthopedic Surgery, Baro Seomyeon Hospital, Busan
| | - Hyunwoo Kim
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Eugene J Park
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Daniel K Park
- Department of Orthopedic Surgery, Michigan Orthopedic Surgeons, Southfield, MI
| |
Collapse
|
6
|
Andriamifidy HF, Rohde M, Swami P, Liang H, Grande D, Virk S. Influence of Placement of Lumbar Interbody Cage on Subsidence Risk: Biomechanical Study. World Neurosurg 2024; 183:e440-e446. [PMID: 38154684 DOI: 10.1016/j.wneu.2023.12.118] [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: 10/25/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Lumbar spinal fusion is a common surgical procedure that can be done with a variety of different instrumentation and techniques. Despite numerous research studies investigating subsidence risk factors, the impact of cage placement on subsidence is not fully elucidated. This study aims to determine whether placement of an expandable transforaminal lumbar interbody fusion cage at the center end plate or at the anterior apophyseal ring affects cage subsidence. METHODS A transforaminal lumbar interbody fusion cage was placed centrally or peripherally between 2 synthetic vertebral models of L3 and L4. A compression plate attached to a 10 KN load cell was used to uniaxially compress the assembly. The ultimate force required for the assembly to fail and subsidence stiffness were analyzed. Computed tomography scans of each L3 and L4 were obtained, and maximum end plate subsidence was measured in the frontal plane. RESULTS Anterior apophyseal cage placement resulted in higher stiffness of the vertebrae-cage assembly (Ks, 962.89 N/mm) and a higher subsidence stiffness (Kb,987.21 N/mm) compared with central placement (P < 0.05). Ultimate compressive load of the vertebrae-cage assembly did not increase. Moreover, the maximum subsidence depth did not significantly vary between placements. CONCLUSIONS The subsidence stiffness increased with anterior apophyseal cage placement. Periphery end plate cortical bone architecture may play a role in resisting the impact of cage subsidence. To fully understand the effect of cage placement on cage subsidence, future studies should investigate its implications on native and diseased spine.
Collapse
Affiliation(s)
| | - Matthew Rohde
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
| | - Pooja Swami
- Department of Orthopaedic Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Haixiang Liang
- Department of Orthopaedic Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Daniel Grande
- Department of Orthopaedic Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sohrab Virk
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Manhasset, New York, USA
| |
Collapse
|
7
|
Li JR, Yan Y, Wu XG, He LM, Feng HY. Biomechanical evaluation of Percutaneous endoscopic posterior lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion: a biomechanical analysis. Comput Methods Biomech Biomed Engin 2024; 27:285-295. [PMID: 36847747 DOI: 10.1080/10255842.2023.2183348] [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: 11/14/2022] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 03/01/2023]
Abstract
In order to analyze and evaluate the stability of lumbar spine and the risk of cage subsidence after different minimally invasive fusion operations, two finite element models Percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) and minimally invasive transforaminal lumbar interbody Fusion (MIS-TLIF) were established. The results showed that compared with MIS-TLIF, PE-PLIF had better segmental stability, lower pedicle screw rod system stress, and lower risk of cage subsidence. The results suggest that the cage with appropriate height should be selected to ensure the segmental stability and avoid the risk of the subsidence caused by the cage with large height.
Collapse
Affiliation(s)
- Jia-Rui Li
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Yang Yan
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Xiao-Gang Wu
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, China
| | - Li-Ming He
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Hao-Yu Feng
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| |
Collapse
|
8
|
Segi N, Nakashima H, Shinjo R, Kagami Y, Machino M, Ito S, Ouchida J, Imagama S. Reply to "Letter to the Editor Concerning 'Trabecular Bone Remodeling as a New Indicator of Osteointegration After Posterior Lumbar Interbody Fusion.' by Segi et al.". Global Spine J 2024; 14:353-354. [PMID: 36880152 PMCID: PMC10676159 DOI: 10.1177/21925682231162860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Affiliation(s)
- Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuichi Shinjo
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Yujiro Kagami
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Ouchida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
9
|
He J, Luo F, Fang Q, Xu J, Zhang Z. Reverse Lumbar Pedicle Screw in Oblique Lateral Interbody Fusion: A Novel Concept to Restrict Cage Subsidence. Orthop Surg 2023; 15:3193-3201. [PMID: 37873589 PMCID: PMC10694012 DOI: 10.1111/os.13898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVE Cage subsidence is a common morbidity after oblique lumbar interbody fusion (OLIF), with risk of compromising clinical and radiographic outcomes. The study aims to describe an innovative reverse lumbar pedicle screw (RLPS) technique in OLIF and compare its effect on restricting cage subsidence with classical lateral fixation (LF) in radiological and clinical evaluation. METHOD Consecutive patients having undergone single-level OLIF-LF/RLPS from 2018 to 2020 were retrospectively reviewed. In OLIF-RLPS, the upper entry point was determined at the intersection between one horizontal line (1 cm above inferior endplate) and one vertical line (dissecting anterior and middle thirds of the vertebra) while the inferior entry point between one horizontal line (5 mm below superior endplate) and the same vertical line. Trajectories were from vertebrae reverse into contralateral pedicle. Radiological evaluation included disc height (DH) and segmental lordosis (SL); cage subsidence was evaluated by DH loss. Clinical assessment included visual analogue scale (VAS) and Oswestry disability index (ODI). Student t or Mann-Whitney U test was used for continuous variation according to normality analysis while Chi-square test for category variation. RESULTS A total of 29 patients had been enrolled in the study including 14 cases in the RLPS group and 15 cases in the LF group. The DH in the OLIF-RLPS group had increased from the preoperative 9.07 ± 1.73 mm to 13.73 ± 1.83 mm postoperatively, without significant difference compared with the OLIF-LF group during the perioperative, but decreased to 12.53 ± 1.74 mm in 3 months and maintained at 12.00 ± 1.45 mm in 12 months, significantly higher than the OLIF-LF group (p < 0.05). At the last follow-up, 7.1% (1/14) cases in the OLIF-RLPS group had shown subsidence of grade I, significantly less than 46.7% (7/15) cases in the OLIF-LF group. Pain and disability had improved similarly in two groups, without significant difference detected between two groups at the last follow-up. CONCLUSION RLPS technique with modified entry points and prolonged trajectory could effectively restrict cage subsidence in OLIF postoperatively compared with traditional lateral fixation.
Collapse
Affiliation(s)
- Jinyue He
- Department of Orthopaedics, Southwest HospitalArmy Medical UniversityChongqingChina
| | - Fei Luo
- Department of Orthopaedics, Southwest HospitalArmy Medical UniversityChongqingChina
| | - Qing Fang
- Department of Orthopaedics, Southwest HospitalArmy Medical UniversityChongqingChina
| | - Jianzhong Xu
- Department of Orthopaedics, Southwest HospitalArmy Medical UniversityChongqingChina
| | - Zehua Zhang
- Department of Orthopaedics, Southwest HospitalArmy Medical UniversityChongqingChina
| |
Collapse
|
10
|
Di M, Weng Y, Wang G, Bian H, Qi H, Wu H, Chen C, Dou Y, Wang Z, Ma X, Xu B, Zhu S, Lu WW, Yang Q. Cortical Endplate Bone Density Measured by Novel Phantomless Quantitative Computed Tomography May Predict Cage Subsidence more Conveniently and Accurately. Orthop Surg 2023; 15:3126-3135. [PMID: 37853959 PMCID: PMC10694013 DOI: 10.1111/os.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE Previous studies have shown that bone mineral density (BMD) is a predictor of cage subsidence. Phantom-less quantitative computed tomography (PL-QCT) can measure volumetric bone mineral density (vBMD) of lumbar trabecular and cortical bone. The study of endplate vBMD (EP-vBMD) is important in predicting cage settlement after extreme lateral interbody fusion (XLIF). This study aimed to determine the risk factors for postoperative cage subsidence after XLIF, particularly focusing on the relationship between vBMD measured by automatic PL-QCT and cage subsidence. METHODS Patients who underwent XLIF surgery from January 2018 to October 2020 with a minimum of 6 months of follow-up were retrospectively included. Cage subsidence was defined as >2 mm cage sinking on the adjacent endplate in follow-up imaging evaluation. Outcome measures were localized vBMDs included EP-vBMDs with different region of interest (ROI) heights measured by PL-QCT based on a customized muscle-fat algorithm. Shapiro-Wilk test, one-way ANOVA, Mann-Whitney test, Fisher exact test, univariable and multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were executed in this study. RESULTS One hundred and thirteen levels of 78 patients were included in the analysis. The mean age was 65 ± 7.9 years for 11 males and 67 females. Cage subsidence occurred on 45 (39.8%) surgical levels. There was no significant difference in demographics, fused levels, or preoperative radiographic parameters. 1.25-mm EP-vBMD (0.991 [0.985,0.997], p = 0.004) and P-TB-vBMD (cage-positioned trabecular volumetric bone mineral density) (0.988 [0.977-0.999], p = 0.026) were cage-subsidence relevant according to univariate analysis. Low 1.25-mm EP-vBMD (0.992 [0.985, 0.999], p = 0.029) was an independent risk factor according to multifactorial analysis. CONCLUSION Preoperative low EP-vBMD was an independent risk factor for postoperative cage subsidence after XLIF. EP-vBMD measured by most cortex-occupied ROI may be the optimal vBMD parameter for cage subsidence prediction.
Collapse
Affiliation(s)
- Mingyuan Di
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Yuanzhi Weng
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Guohua Wang
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Hanming Bian
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Huan Qi
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Hongjin Wu
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Chao Chen
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Yiming Dou
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Zhi Wang
- Tianjin Hospital of Tianjin UniversityTianjinChina
| | - Xinlong Ma
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Baoshan Xu
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Shan Zhu
- Tianjin Hospital of Tianjin UniversityTianjinChina
| | - Weijia William Lu
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Qiang Yang
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| |
Collapse
|
11
|
Piple AS, Ungurean V, Raji OR, Rowland A, Schlauch A, Kondrashov DG, Hsu K, Zucherman J. An Analysis of a Decade of Lumbar Interbody Cage Failures in the United States: A MAUDE Database Study. Spine (Phila Pa 1976) 2023; 48:1652-1657. [PMID: 36727830 DOI: 10.1097/brs.0000000000004583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective case series. OBJECTIVE This study aims to assess the rates of lumbar interbody cage failures based on their material and manufacturer. SUMMARY OF BACKGROUND DATA Perioperative lumbar interbody cage malfunctions are underreported events in the spine literature and may result in complications. Although the Food and Drug Administration ensures the safety of these devices under physiological conditions after implantation, these devices may experience nonphysiological conditions during implantation, which may be overlooked. MATERIALS AND METHODS The MAUDE database was examined for reports of lumbar cage device malfunctions from 2012 to 2021. Each report was categorized based on failure type and implant design. A market analysis was performed by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the United States. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index. RESULTS Overall, 1875 lumbar cage malfunctions were identified. Of these, 1230 (65.6%) were cage breakages, 257 (13.7%) were instrument malfunctions, 177 (9.4%) were cage migrations, 143 (7.6%) were assembly failures, 70 (4.5%) were screw-related failures, and 21 (1.1%) were cage collapses. Of the breakages, 923 (74.9%) occurred during insertion or impaction and 97 entries detailed a medical complication or a retained foreign body. Of the migrations, 155 (88.6%) were identified postoperatively, of which 73 (47.1%) detailed complications and 52 (33.5%) required a revision procedure. Market analysis demonstrated that Medtronic, Zimmer Biomet, Stryker, Seaspine, and K2M exceeded the calculated threshold. CONCLUSIONS Lumbar cages with polyether ether ketone core material failed more frequently by breakage, whereas titanium surface cages failed more frequently by migration. Failure rates varied depending on the manufacturer. Most cage breakages identified in the present study occurred intraoperatively during implantation. These findings call for a more detailed Food and Drug Administration evaluation of these intraoperative malfunctions before commercial approval. LEVEL OF EVIDENCE Level 4.
Collapse
Affiliation(s)
| | | | - Oluwatodimu R Raji
- The Taylor Collaboration, San Francisco, CA
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
| | - Andrea Rowland
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
| | - Adam Schlauch
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
| | - Dimitriy G Kondrashov
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
- SF Spine Surgeons, San Francisco, CA
| | - Ken Hsu
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
- SF Spine Surgeons, San Francisco, CA
| | - James Zucherman
- The Taylor Collaboration, San Francisco, CA
- Department of Orthopaedic Surgery, SF Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
- SF Spine Surgeons, San Francisco, CA
| |
Collapse
|
12
|
Zhang Y, Nüesch C, Mündermann A, Halbeisen F, Schären S, Netzer C. Is Age a Risk Factor for Early Postoperative Cage Subsidence After Transforaminal Lumbar Interbody Fusion? A Retrospective Study in 170 Patients. Global Spine J 2023:21925682231217692. [PMID: 38124312 DOI: 10.1177/21925682231217692] [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: 12/23/2023] Open
Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVES We aim to evaluate whether age is a risk factor for cage subsidence, and whether other patient characteristics, preoperative radiological or imaging parameters are associated with cage subsidence and the need for revision surgery in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS Patient demographics and surgery-related information were extracted. Cage subsidence was evaluated using upright standing sagittal plane X-rays and defined as more than 2 mm migration of the cage into the adjacent vertebral body. Patients who received revision surgery within 1 year for any reason were recorded. Radiographic parameters were measured. Univariable logistic regression models were used to evaluate the risk factors for cage subsidence and need for revision surgery. RESULTS At 3-month and 1-year follow-up, cage subsidence was observed in 28 patients (16.5%) and 58 patients (34.1%), respectively. Twenty-seven patients received revision surgery within the first year after TLIF. Age (odds ratio (OR): 1.07 per year) and male sex (OR: 2.76) had a significantly increased odds ratio for cage subsidence 3 months after TLIF. Male sex (OR: 2.55) but not age was a significant risk factor for cage subsidence 1 year after TLIF. Of all assessed risk factors, only BMI (OR: 1.11 per kg/m2) had a significantly increased risk for the need of revision surgery. CONCLUSIONS Age was associated with cage subsidence 3 months but not 1 year after TLIF suggesting that age is only a risk factor for early cage subsidence and not in a longer follow-up.
Collapse
Affiliation(s)
- Yuancheng Zhang
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Corina Nüesch
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Annegret Mündermann
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Florian Halbeisen
- Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Stefan Schären
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Cordula Netzer
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| |
Collapse
|
13
|
Li Y, Gao SJ, Hu X, Lin SS. Comparison of efficacy between unilateral biportal endoscopic lumbar fusion versus minimally invasive transforaminal lumbar fusion in the treatment of lumbar degenerative diseases: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e34705. [PMID: 37653732 PMCID: PMC10470694 DOI: 10.1097/md.0000000000034705] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/28/2023] [Accepted: 07/20/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND To evaluate the clinical efficacy and prognosis of unilateral biportal endoscopic lumbar fusion (ULIF) and minimally invasive transforaminal lumbar fusion (MIS-TLIF) for lumbar degenerative diseases. METHODS Chinese and English databases were retrieved for the period from database creation to December 31, 2022. Case-control studies on unilateral biportal endoscopic lumbar fusion were collected. The observation indexes consisted of operation times, intraoperative blood loss, postoperative drainage volume, length of hospital stay, postoperative pain score, postoperative oswestry disability index score, postoperative MacNab excellent and good rate, imaging fusion rate at the last follow-up, and complications. The NO rating table was employed to assess the quality of the included literature, and a meta-analysis was conducted using Revman5.4.1 and Stata17. RESULTS Ten studies with 738 surgical patients were considered, including 347 patients in the ULIF group and 391 in the MIS-TLIF group. This Meta-analysis demonstrated statistically significant differences in mean operation duration, intraoperative blood loss, postoperative drainage volume, length of hospital stay, and early postoperative (1-2W) visual analogue scale/score (VAS) scores for back pain. No significant differences were observed in the final follow-up postoperative VAS scores for back pain, postoperative leg VAS score, postoperative oswestry disability index score, excellent and good rate of postoperative modified MacNab, imaging fusion rate, and complications. CONCLUSION Compared with the MIS-TLIF group, the ULIF group had longer operation time, lower intraoperative blood loss and postoperative drainage volume, lower lumbar VAS score in the early postoperative period, and shorter hospital stay. ULIF is less invasive than traditional MIS-TLIF, making it a trustworthy surgical option for lumbar degenerative diseases with comparable fusion efficiency, superior MacNab rate, and complication rate.
Collapse
Affiliation(s)
- Yang Li
- Shengli Clinical College of Fujian Medical University, Fuzhou, China
| | - Shang Jun Gao
- Department of Orthopedic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Spinal Nerve and Joint Diseasess, Fuzhou, China
| | - Xu Hu
- Department of Orthopedic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Spinal Nerve and Joint Diseasess, Fuzhou, China
| | - Shi Shui Lin
- Department of Orthopedic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Spinal Nerve and Joint Diseasess, Fuzhou, China
| |
Collapse
|
14
|
Armocida D, Proietti L, Frati A. Letter to editor regarding: "Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion.". Spine J 2023:S1529-9430(23)00189-4. [PMID: 37149151 DOI: 10.1016/j.spinee.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Daniele Armocida
- Human Neurosciences Department Neurosurgery Division "Sapienza" University, Rome (RM), Italy; IRCCS "Neuromed" Pozzilli (IS), Italy.
| | - Luca Proietti
- Division of Spinal Surgery IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy; Institute of Orthopaedic, Università Cattolica del Sacro Cuore, Rome, Italy
| | | |
Collapse
|
15
|
Zou D, Yue L, Fan Z, Zhao Y, Leng H, Sun Z, Li W. Biomechanical Analysis of Lumbar Interbody Fusion Cages With Various Elastic Moduli in Osteoporotic and Non-osteoporotic Lumbar Spine: A Finite Element Analysis. Global Spine J 2023:21925682231166612. [PMID: 37132375 DOI: 10.1177/21925682231166612] [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: 05/04/2023] Open
Abstract
STUDY DESIGN Finite element analysis (FEA). OBJECTIVE This study aimed to explore the effects of cage elastic modulus (Cage-E) on the endplate stress in different bone conditions: osteoporosis (OP) and non-osteoporosis (non-OP). We also explored the correlation between endplate thickness and endplate stress. METHOD The FEA models of L4-L5 with lumbar interbody fusion were designed to access the effects of Cage-E on the endplate stress in different bone conditions. Two groups of the Young's moduli of bony structure were assigned to simulate the conditions of OP and non-OP, and the bony endplates were analyzed in 2 kinds of thicknesses: .5 mm and 1.0 mm, with the insertion of cages with different Young's moduli including .5, 1.5, 3, 5, 10, and 20 GPa. After model validation, an axial compressive load of 400 N and a flexion/extension moment of 7.5Nm was performed on the superior surface of L4 vertebral body in order to analyze the distribution of stress. RESULT The maximum Von Mises stress in the endplates increased by up to 100% in the OP model compared with non-OP model under the same condition of cage-E and endplate thickness. In both OP and non-OP models, the maximum endplate stress decreased as the cage-E decreased, but the maximum stress in the lumbar posterior fixation increased as the cage-E decreased. Thinner endplate thickness was associated with increased endplate stress. CONCLUSION The endplate stress is higher in osteoporotic bone than non-osteoporotic bone, which explains part of the mechanism of OP-related cage subsidence. It is reasonable to reduce the endplate stress by reducing the cage-E, but we should balance the risk of fixation failure. Endplate thickness is also important when evaluating the cage subsidence risk.
Collapse
Affiliation(s)
- Da Zou
- Orthopaedics Department, Peking University Third Hospital, China
- Ministry of Education, Engineering Research Center of Bone and Joint Precision Medicine, China
- Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, China
| | - Lihao Yue
- Orthopaedics Department, Peking University Health Science Center, China
| | - Zheyu Fan
- Orthopaedics Department, Peking University Health Science Center, China
| | - Yi Zhao
- Orthopaedics Department, Peking University Health Science Center, China
| | - Huijie Leng
- Orthopaedics Department, Peking University Third Hospital, China
- Ministry of Education, Engineering Research Center of Bone and Joint Precision Medicine, China
- Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, China
| | - Zhuoran Sun
- Orthopaedics Department, Peking University Third Hospital, China
- Ministry of Education, Engineering Research Center of Bone and Joint Precision Medicine, China
- Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, China
| | - Weishi Li
- Orthopaedics Department, Peking University Third Hospital, China
- Ministry of Education, Engineering Research Center of Bone and Joint Precision Medicine, China
- Orthopaedics Department, Beijing Key Laboratory of Spinal Disease Research, China
| |
Collapse
|
16
|
Pao JL. Biportal Endoscopic Transforaminal Lumbar Interbody Fusion Using Double Cages: Surgical Techniques and Treatment Outcomes. Neurospine 2023; 20:80-91. [PMID: 37016856 PMCID: PMC10080423 DOI: 10.14245/ns.2346036.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023] Open
Abstract
Objective: To describe the surgical techniques and the treatment outcomes of biportal endoscopic transforaminal lumbar interbody fusion (BETLIF) using double cages.Methods: This study included 89 patients with 114 fusion segments between July 2019 and May 2021. One pure polyetheretherketone (PEEK) cage and 1 composite titanium-PEEK cage were used for interbody fusion. Clinical outcomes measures included visual analogue scale (VAS) scores for lower back pain and leg pain, Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) scores. Computed tomography (CT) of the lumbar spine 1 year postoperatively was used to evaluate the Bridwell interbody fusion grades.Results: There were significant improvement in VAS for lower back pain from 5.2 ± 3.1 to 1.7 ± 2.1, VAS for leg pain from 6.3 ± 2.5 to 1.7 ± 2.0, ODI from 46.7 ± 17.0 to 12.7 ± 16.1, and JOA score from 15.6 ± 6.3 to 26.4 ± 3.2. The p-values were all < 0.001. The average hospital stay was 5.7 ± 1.1 days. The CT studies available for 60 fusion segments showed successful fusion (Bridwell grade I or grade II) in 56 segments (93.3%). Significant cage subsidence of more than 2 mm was only noted in 3 segments (5.0%). Complications included 1 dural tear, 2 pedicle screws malposition, and 2 epidural hematomas, in which 2 patients required reoperations.Conclusion: BETLIF with double cages provided good neural decompression and a sound environment for interbody fusion with a big cage footprint, a large amount of bone graft, endplate preservation, and segmental stability.
Collapse
Affiliation(s)
- Jwo-Luen Pao
- Department of Orthopedic Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
- Longhwa University of Science and Technology, Taoyuan, Taiwan
- Corresponding Author Jwo-Luen Pao Department of Orthopedic Surgery, Far-Eastern Memorial Hospital, 21, Section 2, Nanya South Road, Banqiao District, New Taipei 22060, Taiwan
| |
Collapse
|
17
|
Fushimi K, Miyagawa T, Iwai C, Nozawa S, Iinuma N, Tanaka R, Shirai G, Tanahashi H, Yokoi T, Akiyama H. Transforaminal Lumbar Interbody Fusion with Double Banana Cages: Clinical Evaluations and Finite Element Model Analysis. Global Spine J 2023:21925682231165709. [PMID: 36944178 DOI: 10.1177/21925682231165709] [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: 03/23/2023] Open
Abstract
STUDY DESIGN Clinical and basic study. OBJECTIVES This study aimed to investigate whether transforaminal lumbar interbody fusion (TLIF) using 2 banana-shaped cages leads to good clinical outcomes. METHODS First, we conducted a clinical study to compare outcomes among patients who underwent TLIF using different types or numbers of cages. Propensity matched patients in each group were reviewed. Thirty-four patients who underwent surgery with 2 bullet-shaped cages (group A), 34 with a banana-shaped cage (group B), and 34 with 2 banana-shaped cages (group C) were compared. Twelve months after the surgery, bony fusion and cage subsidence were evaluated. RESULTS The mean amount of cage subsidence was 14.9% in group A, 19.9% in group B, and 11.8% in group C. Subsidence in group B was significantly greater than that in group C (P < .01). Radiological bony fusion was not achieved in 2 cases in group B. Second, we performed a finite element model (FEM) analysis to determine the biomechanical stress of the vertebral endplate by comparing the single-banana cage construct with a double banana-shaped cage construct. FEM analysis showed that the maximum stress of the endplate in the single-cage model was 1.72-times greater than the maximum stress in the double-cage model. Furthermore, the maximal stress in the single-cage model was significantly higher than in the double-cage model during lumbar extension and side bending. CONCLUSION This study showed that TLIF with double banana-shaped cages led to good clinical outcomes with less cage subsidence, probably because of decreased mechanical stress on the vertebral endplate.
Collapse
Affiliation(s)
- Kazunari Fushimi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takaki Miyagawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chizuo Iwai
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Nozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuki Iinuma
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ryo Tanaka
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Goshi Shirai
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hiroyuki Tanahashi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tatsuo Yokoi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| |
Collapse
|
18
|
Toop N, Dhaliwal J, Grossbach A, Gibbs D, Reddy N, Keister A, Mallory N, Xu D, Viljoen S. Subsidence Rates Associated With Porous 3D-Printed Versus Solid Titanium Cages in Transforaminal Lumbar Interbody Fusion. Global Spine J 2023:21925682231157762. [PMID: 36786680 DOI: 10.1177/21925682231157762] [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: 02/15/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE To determine whether 3D-printed porous titanium (3DPT) interbody cages offer any clinical or radiographic advantage over standard solid titanium (ST) interbody cages in transforaminal lumbar interbody fusions (TLIF). METHODS A consecutive series of adult patients undergoing one- or two-level TLIF with either 3DPT or ST "banana" cages were analyzed for patient reported outcome measures (PROMs), radiographic complications, and clinical complications. Exclusion criteria included clinical or radiographic follow-up less than 1 year. RESULTS The final cohort included 90 ST interbody levels from 74 patients, and 73 3DPT interbody levels from 50 patients for a total of 124 patients. Baseline demographic variables and comorbidity rates were similar between groups (P > .05). Subsidence of any grade occurred more frequently in the ST group compared with the 3DPT group (24.4% vs 5.5%, respectively, P = .001). Further, the ST group was more likely to have higher grades of subsidence than the 3DPT group (P = .009). All PROMs improved similarly after surgery and revision rates did not differ between groups (both P > .05). On multivariate analysis, significant positive correlators with increasing subsidence grade included greater age (P = .015), greater body mass index (P = .043), osteoporosis/osteopenia (P < .027), and ST cage type (P = .019). CONCLUSIONS When considering interbody material for TLIF, both ST and 3DPT cages performed well; however, 3DPT cages were associated with lower rates of subsidence. The clinical relevance of these findings deserves further randomized, prospective investigation.
Collapse
Affiliation(s)
- Nathaniel Toop
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Joravar Dhaliwal
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Andrew Grossbach
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - David Gibbs
- Ohio State University School of Medicine, Columbus, OH, USA
| | - Nihaal Reddy
- Ohio State University School of Medicine, Columbus, OH, USA
| | | | - Noah Mallory
- Ohio State University School of Medicine, Columbus, OH, USA
| | - David Xu
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Stephanus Viljoen
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| |
Collapse
|
19
|
Yao YC, Chao H, Kao KY, Lin HH, Wang ST, Chang MC, Liu CL, Chou PH. CT Hounsfield unit is a reliable parameter for screws loosening or cages subsidence in minimally invasive transforaminal lumbar interbody fusion. Sci Rep 2023; 13:1620. [PMID: 36709341 PMCID: PMC9884280 DOI: 10.1038/s41598-023-28555-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/20/2023] [Indexed: 01/30/2023] Open
Abstract
Retrospective cohort study. To validate computed tomography (CT) radiodensity in Hounsfield units (HU) as a prognostic marker for pedicle screw loosening or cage subsidence in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The retrospective study involved 198 patients treated with MI-TLIF. Screw loosening (SL), cage subsidence (CS), and fusion status were assessed by plain radiographs. The risk factors of SL and CS were identified using logistic regression. A total of 258 levels and 930 screws were analyzed. During a 2-year follow-up, 16.2% and 24.7% of patients had CS and SL respectively. The cut-off value of L1 HU for predicting SL or CS was 117. The L1 HU < 117 and BMI ≥ 25 were two independent risk factors. The risk of SL or CS was 4.1 fold in patients L1 HU < 117 and 2.6 fold in patients with BMI ≥ 25. For patients concurrently having BMI ≥ 25 and pre-op L1 HU < 117, the risk was 4.3 fold. Fusion rate and clinical outcome were comparable in patients with SL or CS. L1 HU < 117 and BMI > 25 were two independent risk factors that can be screened preoperatively for preventing SL or CS and lead to better management of patients undergoing MI-TLIF.
Collapse
Affiliation(s)
- Yu-Cheng Yao
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsien Chao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kun-Yu Kao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medical Education, Chi Mei Hospital, Tainan, Taiwan
| | - Hsi-Hsien Lin
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Tien Wang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Ming-Chau Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Lin Liu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hsin Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
20
|
Sun B, Han Q, Sui F, Zhang A, Liu Y, Xia P, Wang J, Yang X. Biomechanical analysis of customized cage conforming to the endplate morphology in anterior cervical discectomy fusion: A finite element analysis. Heliyon 2023; 9:e12923. [PMID: 36747923 PMCID: PMC9898605 DOI: 10.1016/j.heliyon.2023.e12923] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
In anterior cervical discectomy and fusion (ACDF), an interbody fusion device is an essential implant. An unsuitable interbody fusion device can cause postoperative complications, including subsidence and nonunion. We designed a customized intervertebral fusion device to reduce postoperative complications and validated it by finite element analysis. Herein, we built a non-homogeneous model of the C3-7 cervical spine. Three implant models (customized cage, commercial cage, and bone graft cage) were constructed and placed in the C45 cervical segment after ACDF surgery. The simulated range of motion (ROM), stress at the cage-bone interface, and stress on the cage and implants were compared under different conditions. The commercial cage showed maximum stress peaks at 40.3 MPa and 43.2 MPa in the inferior endplate of C4 and superior endplate of C5 under rotational conditions, higher compared to 29.7 MPa and 26.4 MPa, respectively, in the customized cage. The ROM was not significantly different between the three cages placed after ACDF. The stresses on the commercial cage were higher compared to the other two cages under all conditions. The bone graft in the customized cage was subject to higher stress than the commercial cage under all conditions, particularly lateral bending, wherein the maximum stress was 5.5 MPa. These results showed that a customized cage that better conformed to the vertebral anatomy was promising for reducing the risk of stress shielding and the occurrence of subsidence.
Collapse
|
21
|
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.
Collapse
|