Comparison of the different surgical approaches for lumbar interbody fusion

Percutaneous endoscopic posterior lumbar interbody fusion for the treatment of degenerative lumbar diseases: a technical note and summary of the initial clinical outcomes

BACKGROUND

Percutaneous endoscopic lumbar interbody fusion was a new technique that leads to improved visualization, improved safety and less trauma than does the traditional procedure. The purpose of this study was to introduce the technique of percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) and determine its efficacy.

METHODS

35 patients with an average age of 52.3±13.7 years were treated with single-segment PE-PLIF. The perioperative parameters and the radiographic parameters were measured. The visual analog scale (VAS) score for low back pain, VAS score for leg pain and Oswestry disability index (ODI) score were used to assess the levels of pain and function.

RESULTS

The mean estimated volume of blood loss was 68.6±32.3 ml, operative time was 179.6±31.0 minutes. PE-PLIF significantly reduced the VAS score for low back pain, VAS score for leg pain and ODI score, and improved the posterior disc height, lumbar lordosis angle and segmental lordosis angle (p < 0.05). The rate of satisfaction was 94.3%. One patient suffered a dural tear. There was one case of contralateral radiculopathy that was relieved after conservative treatment.

CONCLUSIONS

This research suggests that PE-PLIF is a minimally invasive, safe, and effective treatment for degenerative lumbar diseases requiring interbody fusion.

Clinical outcome after dorso-ventral stabilization of the thoracolumbar and lumbar spine with vertebral body replacement and dorsal stabilization

PURPOSE

Surgical stabilization of the spine by vertebral body replacement (VBR) is used for spinal disorders such as traumatic fractures to provide an anatomical re-adjustment of the spine to prevent late detrimental effects and pain [1-4]. This study addresses the clinical outcome after a ventral intervention with VBR and bisegmental fusion.

METHODS

The study includes 76 patients (mean age: 59.34 ± 15.97; 34 females and 42 males) with fractures in the lower thoracic and lumbar spine. They were selected from patients of our hospital who received an anterolateral VBR surgery on the corresponding lower spine region over a nine-year period. Only patients were examined with X-rays and complete follow-up records. Exclusion criteria were changes due to degeneration and pathological fractures. Patients were divided into two groups, the thoracotomy group (Th10-L1) and the lumbotomy group (L2-5), respectively. Minimum one year after surgery, patients were asked about their well-being using a precasted questionnaire.

RESULTS

No significant differences with respect to the subjective impression of the patients concerning their back pain, spinal functional impairment, their general functional status and their quality of life impairment. Unfortunately, however, only a rather modest but significant increase of the post-surgical life quality was reported.

CONCLUSIONS

Patients who underwent VBR in the lower thoracic or lumbar spine show modest long-term well-being. The results suggest that injuries to the lower thoracic or lumbar spine requiring vertebral body replacement should be classified as severe injuries since they adversely affect the patients' long-term well-being.

TRIAL REGISTRATION

Study of clinical outcome of patients after vertebral body replacement of the ventral thoracal and lumbal spine, DRKS00031452. Registered 10th March 2023 - Prospectively registered. Trial registration number DRKS00031452.

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database

STUDY DESIGN

Retrospective review of multicentric data.

OBJECTIVES

The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery.

METHODS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics.

RESULTS

53 252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30 days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery.

CONCLUSION

The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery.

Comparing the osteogenesis outcomes of different lumbar interbody fusions (A/O/X/T/PLIF) by evaluating their mechano-driven fusion processes

BACKGROUND

In lumbar interbody fusion (LIF), achieving proper fusion status requires osteogenesis to occur in the disc space. Current LIF techniques, including anterior, oblique, lateral, transforaminal, and posterior LIF (A/O/X/T/PLIF), may result in varying osteogenesis outcomes due to differences in biomechanical characteristics.

METHODS

A mechano-regulation algorithm was developed to predict the fusion processes of A/O/X/T/PLIF based on finite element modeling and iterative evaluations of the mechanobiological activities of mesenchymal stem cells (MSCs) and their differentiated cells (osteoblasts, chondrocytes, and fibroblasts). Fusion occurred in the grafting region, and each differentiated cell type generated the corresponding tissue proportional to its concentration. The corresponding osteogenesis volume was calculated by multiplying the osteoblast concentration by the grafting volume.

RESULTS

TLIF and ALIF achieved markedly greater osteogenesis volumes than did PLIF and O/XLIF (5.46, 5.12, 4.26, and 3.15 cm3, respectively). Grafting volume and cage size were the main factors influencing the osteogenesis outcome in patients treated with LIF. A large grafting volume allowed more osteoblasts (bone tissues) to be accommodated in the disc space. A small cage size reduced the cage/endplate ratio and therefore decreased the stiffness of the LIF. This led to a larger osteogenesis region to promote osteoblastic differentiation of MSCs and osteoblast proliferation (bone regeneration), which subsequently increased the bone fraction in the grafting space.

CONCLUSION

TLIF and ALIF produced more favorable biomechanical environments for osteogenesis than did PLIF and O/XLIF. A small cage and a large grafting volume improve osteogenesis by facilitating osteogenesis-related cell activities driven by mechanical forces.

The Prone Lateral Approach for Lumbar Fusion-A Review of the Literature and Case Series

Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon's ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.

Comparison of oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of degenerative lumbar diseases: A protocol for systematic review and meta-analysis

BACKGROUND

Degenerative lumbar diseases are common in the aging population, and is one of the most frequent causes of disability. Lumbar fusion is an effective surgical procedure for alleviating pain and improving function. A variety of fusion techniques applied where necessary are available and the optimal method remains controversial. We performed a protocol for systematic review and meta-analysis to compare the clinical efficacy of oblique lateral interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar diseases.

METHODS

This systematic review protocol will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) 2015 Statement.Following databases will be searched: PubMed, web of science, MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang data, and Chinese BioMedicine Literature Database. Only randomized controlled trials comparing OLIF and TLIF for treating degenerative lumbar diseases will be included. The meta-analysis will be performed with Review Manager Version 5.4 software (The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

The results of this systematic review will be published in a peer-reviewed journal.

CONCLUSION

This study will elucidate the clinical outcomes of OLIF compared with TLIF in treating degenerative lumbar diseases.

Functional outcome of surgical management of low mid-grade lumbar spondylolisthesis when considering the sagittal balance parameters preoperatively: a prospective study

BACKGROUND

Prospective study objectives. A sagittal balance is a good tool to improve the functional outcome of spine spondylolisthesis surgeries, primarily noted that it has a good impact in deformity surgery and then applied to every spine surgery and the aim of this study is to evaluate its functional outcome when considered in preoperative planning for non-dysplastic low- and mid-grade spondylolisthesis surgeries.

METHOD

Forty patients diagnosed as low- or mid-grade non-dysplastic spondylolisthesis had undergone surgery at Cairo University after failed medical treatment had been evaluated preoperatively by measuring the sagittal balance parameters which include SVA, spinopelvic angles, lumbar lordosis, pelvic tilt, sacral slope, and pelvic incidence and then measure it along a follow-up period of 1 year postoperatively started from February 2018 and correlate it with functional outcome using Oswestry score (ODI)and VAS. Correction of parameters has been estimated preoperatively by manual estimation and Surgimap application then applied during the operation.

RESULTS

All patients were treated by surgical treatment through posterior transpedicular screw fixation with conventional or reduction screws and fusion ± TLIF cages. The mean of lumbar lordosis and mean spinopelvic angles were increased in a statistically significant manner. Pelvis tilt was decreased in a statistically insignificant manner. The mean of pelvic incidence was not changed and statistically insignificant, and this is matching the fact that pelvic incidence is a constant parameter. The sacral slope was increased in a statistically insignificant manner. Final results showed that 37 had a statistically significant improvement in their ODI >20% at the last visit. Three patients had a poor clinical outcome with ODI scorFinal results showed that 37 had a statistically significant improvement in their ODI >20% at the last visit. Three patients had a poor clinical outcome with ODI score of >20% improvement, and we noticed that the level of pathology was at the level of L4L5, SVA was positive and worsen postoperatively, and also, it is accompanied by decreased lumbar lordosis. Change in ODI means statistically significant improvement when considering sagittal parameters preoperation and during operation.

CONCLUSION

Sagittal balance parameters should be considered in the surgical management of low-grade spondylolisthesis cases to improve their functional outcome.

Trends in Single-Level Lumbar Fusions Over the Past Decade Using a National Database

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.

Longitudinal Trends of Patient Demographics and Morbidity of Different Approaches in Lumbar Interbody Fusion: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program Database

OBJECTIVE

The aims of this study were to determine the time trend of demographics, complications, and outcomes for patients undergoing posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF) or anterior lumbar interbody fusion/lateral lumbar interbody fusion (ALIF/LLIF) and to compare the differences in the time trends between both procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing PLIF/TLIF and ALIF/LLIF procedures. Outcomes were analyzed for differences between 2 time periods in the PLIF/TLIF and ALIF/LLIF cohorts separately (2009-2013 and 2015-2019). Longitudinal time trends of the 2 procedures were determined by difference-in-differences (DID) analysis. Statistical significance was defined as P < 0.05.

RESULTS

For both approaches, there was an increase in age and American Society of Anesthesiologists class over time, accompanied by a significant decrease in blood transfusions and morbidity. The DID analysis showed a greater change in age (DID:-1.8%; P < 0.001), and more patients were rated American Society of Anesthesiologists class 3 (DID: -2.4%; P = 0.033) in the ALIF/LLIF cohort than in the PLIF/TLIF cohort. Length of stay declined significantly over time in both cohorts, with a greater reduction observed for patients who underwent ALIF/LLIF than for patients who underwent PLIF/TLIF (DID: 0.2%; P = 0.014). There were no changes in readmission rates over time in either cohort (PLIF/TLIF DID: 0.6%; P = 0.080; ALIF/LLIF DID: -0.2%; P = 0.696).

CONCLUSIONS

Time trends for PLIF/TLIF and ALIF/LIIF showed a significant increase in the number of older patients with complex medical status undergoing surgery. Despite these trends, there were decreases in overall postoperative morbidity, incidence of blood transfusion, and length of stay, without increasing readmission. These results suggest general improvement in surgical and perioperative management of lumbar fusion over time with greater gains found in ALIF/LLIF-specific care than in PLIF/TLIF.

Do Radiographic Results of Transforaminal Lumbar Interbody Fusion Vary with Cage Position in Patients with Degenerative Lumbar Diseases?

Objective

To investigate whether the radiographic results are affected by cage position in single‐level transforaminal lumbar interbody fusion (TLIF).

Method

Between January 2016 and June 2018, 130 patients (62 males and 68 females, average age: 55.28 ± 10.11 years) who underwent single‐level TLIF were analyzed retrospectively. Standing lateral radiographs of the lumbar spine were collected and evaluated preoperatively, postoperatively, and at the time of last follow‐up. Cage position in the fused segment was recorded using a central point ratio (CPR), which indicated the cage position. CPR is calculated by dividing the distance between the cage center point and the posterior extent of the superior endplate of the inferior vertebra by the length of the superior endplate of the inferior vertebra. Based on cage positions, the patients were divided into three groups: Anterior Group (n = 38); Middle Group (n = 68); and Posterior Group (n = 24). Segmental lumbar lordosis (SLL), foraminal height (FH), posterior disc height (PDH), and anterior disc height (ADH) were evaluated. A subanalysis was also performed on cage height within each group.

Results

The average follow‐up time of the patients was 35.20 ± 4.43 months. The mean values of CPR in Anterior Group, Middle Group, and Posterior Group were 0.64, 0.51, and 0.37, respectively. The FH, PDH, and ADH were significantly increased after TLIF in all groups (P < 0.05). There were significant differences in increase of SLL in Anterior Group (4.4°) and Middle Group (3.0°), but not in Posterior Group (0.3°). Furthermore, in the comparison of the three groups, the increase of SLL, FH, and PDH was statistically different (P < 0.05), while not for ADH (P > 0.05). The significant correlations in surgery were: CPR and ΔSLL (r = 0.584, P < 0.001), CPR and ΔFH (r = −0.411, P < 0.001), and CPR and ΔPDH (r = −0.457, P < 0.001). However, ADH had a positive correlation with cage height when the cage was located in anterior and middle of the endplate. Moreover, cage height had a positive correlation with SLL when the cage was located anteriorly and had a negative correlation with SLL when the cage was located posteriorly. FH and PDH both had a positive correlation with cage height in any cage position.

Conclusion

The cage located in different positions has different effects on radiographic results in single‐level TLIF. A thicker cage located anteriorly will gain maximum SLL and avoid the reduction of FH and PDH.

Effects of thigh extension on the position of the femoral nerve: application to prone lateral transpsoas approaches to the lumbar spine

Some authors have suggested that thigh extension during the prone lateral transpsoas approach to the lumbar spine provides the theoretical advantage of providing posterior shift of the psoas muscle and plexus and is responsible for its lower rates of nerve injury. We aimed to elucidate the effects of surgical positioning on the femoral nerve within the psoas muscle via a cadaveric study. In the supine position, 10 fresh frozen adult cadavers had a metal wire secured to the pelvic segment of the femoral nerve and then extended proximally along with its L2 contribution. Fluoroscopy was then used to identify the wires on the femoral nerves in a neutral position and with the thigh extended and flexed by 25 and 45°. Additionally, a lateral incision was made in the anterolateral abdominal wall to mimic a lateral transpsoas approach to the lumbar spine, and measurements were made of the amount of movement in the vertical plane of the femoral nerve from neutral to then 25 and 45° of thigh flexion and extension. On fluoroscopy, the femoral nerves moved posteriorly at a mean of 10.1 mm with thigh extension. Femoral nerve movement could not be detected at any degree of this range of flexion of the thigh. Extension of the thigh to about 30° can move the femoral nerve farther away from the dissection plane by approximately one centimeter. This hip extension not only places the femoral nerve in a more advantageous position for lateral lumbar interbody fusion procedures but also helps to promote accentuation of lumbar lordosis.

Open-Label Placebo Treatment for Acute Postoperative Pain (OLP-POP Study): Study Protocol of a Randomized Controlled Trial

Introduction: Open-label placebos have been proposed as way of using long recognized analgesic placebo effects in an ethical manner. Recent evidence shows efficacy of open-label placebos for clinical conditions, but there is need for more research on open-label placebos in acute pain. In the treatment of acute postoperative pain, minimization of opioid related side effects remains one of the key challenges. Therefore, this study aims at investigating the potential of adding unconditioned open-label placebos to treatment as usual as a means of reducing opioid consumption and its related side effects in patients with acute postoperative pain. Methods and Analysis: This is the protocol of an ongoing single site randomized controlled trial. The first patient was enrolled in May 2020. In total, 70 patients suffering from acute postoperative pain following dorsal lumbar interbody fusion are randomized to either a treatment as usual group or an experimental intervention group. The treatment as usual group consists of participants receiving a patient-controlled morphine pump. On day 1 and 2 post-surgery, patients in the intervention group receive, in addition to treatment as usual, two open-label placebo injections per day along with an evidence-based treatment rationale explaining the mechanisms of placebos. The primary outcome is measured by means of self-administered morphine during day 1 and 2 post-surgery. Several other outcome measures including pain intensity and adverse events as well as potential predictors of placebo response are assessed. Analysis of covariance will be used to answer the primary research question and additional statistical techniques such as generalized linear mixed models will be applied to model the temporal course of morphine consumption. Discussion: This study will provide valuable insights into the efficacy of open-label placebos in acute pain and will potentially constitute an important step toward the implementation of open-label placebos in the clinical management of acute postoperative pain. In addition, it will shed light on a cost-efficient and patient-centered strategy to reduce opioid consumption and its related side effects, without any loss in pain management efficacy. Ethics and Dissemination: The "Ethikkommission Nordwest- und Zentralschweiz" (BASEC2020-00099) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal. Clinical Trial Registration: The study is registered at ClinicalTrials.gov (NCT04339023) and is listed in the Swiss national registry at kofam.ch (SNCTP000003720).

Cage or Pelvic Graft-Study on Bony Fusion of the Ventral Thoracic and Lumbar Spine in Traumatic Vertebral Fractures

Background and Objectives: Stabilization of the spine by cage implantation or autologous pelvic bone graft are surgical methods for the treatment of traumatic spine fractures. These methods serve to stably re-adjust the spine and to prevent late detrimental effects such as pain or increasing kyphosis. They both involve ventral interventions using interbody fusion to replace the intervertebral disc space between the vertebral bodies either by cages or autologous pelvic bone grafts. We examined which of these methods serves the patients better in terms of bone fusion and the long-term clinical outcome. Materials and Methods: Forty-six patients with traumatic fractures (12 cages; mean age: 54.08/34 pelvic bone grafts; mean age: 42.18) who received an anterior fusion in the thoracic or lumbar spine were included in the study. Postoperative X-ray images were evaluated, and fusion of the stabilized segment was inspected by two experienced spine surgeons. The time to discharge from hospital and gender differences were evaluated. Results: There was a significant difference of the bone fusion rate of patients with autologous pelvic bone grafts in favor of cage implantation (p = 0.0216). Also, the stationary phase of patients who received cage implantations was clearly shorter (17.50 days vs. 23.85 days; p = 0.0089). In addition, we observed a significant gender difference with respect to the bony fusion rate in favor of females treated with cage implantations (p < 0.0001). Conclusions: Cage implantations after spinal fractures result in better bony fusion rates as compared to autologous pelvic bone grafts and a shorter stay of the patients in the hospital. Thus, we conclude that cage implantations rather than autologous pelvic bone grafts should be the preferred surgical treatment for stabilizing the spine after fracture.

The comparison between anterior and posterior approaches for removal of infected lumbar interbody cages and a proposal regarding the use of endoscope-assisted technique

Background

In cases of postoperative deep wound infection after interbody fusion with cages, it is often difficult to decide whether to preserve or remove the cages, and there is no consensus on the optimal approach for removing cages. The aim of this study was to investigate the surgical management of cage infection after lumbar interbody fusion.

Methods

A retrospective study was conducted between January 2012 and August 2018. Patients were included if they had postoperative deep wound infection and required cage removal. Clinical outcomes, including operative parameters, visual analog scale, neurologic status, and fusion status, were assessed and compared between anterior and posterior approaches for cage removal.

Results

Of 130 patients who developed postoperative infection and required surgical debridement, 25 (27 levels) were diagnosed with cage infection. Twelve underwent an anterior approach, while 13 underwent cage removal with a posterior approach. Significant differences were observed between the anterior and posterior approaches in elapsed time to the diagnosis of cage infection, operative time, and hospital stay. All patients had better or stationary American Spinal Injury Association impairment scale, but one case of recurrence in adjacent disc 3 months after the surgery.

Conclusions

Both anterior and posterior approaches for cage removal, followed by interbody debridement and fusion with bone grafts, were feasible methods and offered promising results. An anterior approach often requires an additional extension of posterior instrumentation due to the high incidence of concurrent pedicle screw loosening. The use of an endoscope-assisted technique is suggested to facilitate safe removal of cages.

Safety of Lumbar Interbody Fusion Procedures for Degenerative Disc Disease: A Systematic Review With Network Meta-Analysis of Prospective Studies

STUDY DESIGN

A network meta-analysis.

OBJECTIVES

Lumbar degenerative disc disease (LDDD) is an important issue in aging population, for which lumbar interbody fusion (LIF) is a feasible management in cases refractory to conservative therapy. There are various techniques available to perform LIF, including posterior (PLIF), transforaminal (TLIF), and anterior (ALIF) approaches. However, the comparative safety profile of these procedures remains controversial. Our study aimed to evaluate comparative adverse events of the LIF procedures in patients with LDDD.

METHODS

We searched 5 databases for relevant prospective cohort studies and randomized clinical trials. After quality assessments, we extracted neural, spinal, vascular, and wound events for conducting contrast-based network meta-analysis. Results were reported in risk ratio (RR), 95% confidence interval (CI), and surface under the cumulative ranking (SUCRA).

RESULTS

We identified 14 studies involving 921 participants with LDDD. Pooled result showed that open PLIF (OPLIF) leads to significantly higher overall adverse event rate than does open TLIF (OTLIF; RR = 3.43, 95% CI = 1.21-9.73). OTLIF confers the highest SUCRA in neural (78.7) and spinal (80.8) event rates. Minimally invasive TLIF has the highest SUCRA in vascular event (84.2), and minimally invasive PLIF has the highest SUCRA in wound event (88.1). No inconsistency or publication bias was detected in the results.

CONCLUSIONS

Based on our results, perhaps OPLIF should be avoided in the management of LDDD due to the inferiority of overall complications. Specifically, TLIF seems to have the safest profile in terms of neural, spinal, and vascular events. Nevertheless, shared decision making is still mandatory when choosing the proper LIF procedure for patients with LDDD in clinical practice.

Variability and contributions to cost associated with anterior versus posterior approaches to lumbar interbody fusion

OBJECTIVE

Lumbar interbody fusions are being performed with increased frequency in the last decade. Anterior and posterior interbody techniques have demonstrated relatively similar success rates. Nonetheless, despite increased attention to cost-effective care delivery, approach-related differences in procedural cost and predictors for these differences remain poorly defined. The purpose of this investigation was to characterize the variability in cost for anterior versus posterior-based lumbar interbody fusions and to identify key predictors of procedural cost.

METHODS

We evaluated the records of all patients who underwent a primary anterior (ALIF) or posterior/transforaminal (PLIF/TLIF) lumbar interbody fusion with concomitant posterior fusion from 2016 to 2020 at four hospitals in a major metropolitan area. We reviewed the records of all included patients and abstracted demographics, insurance status, approach, operative time, diagnosis, surgeon, institution, open versus minimally invasive technique, and components of procedural costs. Costs based upon interbody approach were compared via multivariable adjusted analyses using negative binomial regression.

RESULTS

We included 139 interbody fusion procedures; 98 were performed via posterior approach (TLIF/PLIF) and 41 using an anterior approach. Anterior techniques were associated with significantly increased costs as compared to posterior procedures (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001). This determination remained significant following multivariable adjusted analysis (regression coefficient -0.22, 95% CI -0.34, -0.10, p < 0.001). Multivariable analysis also indicated that surgeon, invasiveness, and procedure time were significant predictors of total cost.

CONCLUSION

Our findings demonstrate that anterior interbody techniques are, on average, 173% (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001) more expensive than posterior-based procedures. Given the relative equipoise of these different approaches for many clinical applications, these findings should be considered in an ecosystem increasingly attentive to cost effective care delivery. This work has also provided specific procedural variables for surgeons and systems to target when optimizing procedural costs.

Lateral Interbody Fusion at L4/5: Management of the Transitional Psoas

OBJECTIVE

Managing retraction of the lumbar plexus is critical to safely perform lateral lumbar interbody fusion (LLIF) via the transpsoas approach. Occasionally, a transitional psoas is encountered at L4/5 and has been postulated to be a contraindication to transpsoas LLIF. A case series of patients with transitional psoas who underwent L4/5 LLIFs is presented.

METHODS

This retrospective review assessed 79 consecutive patients who underwent L4/5 LLIF during a 24-month period. Preoperative imaging was reviewed, and patients were classified into 2 groups: normal psoas or transitional psoas. Intraoperative features and outcomes were compared between groups.

RESULTS

Seventy-nine patients underwent L4/5 LLIFs, of whom 23 had transitional psoas anatomy and 56 had normal psoas anatomy. Among patients with transitional psoas, the center of the psoas was a mean (range) of 11.2 (5.2-26.6) mm in front of the center of the vertebral body compared with 2.0 (0-4) mm in the normal psoas group. The mean (range) retraction time was similar between groups (10.8 [6.7-14.9] minutes in the transitional psoas group vs. 11.0 [7.8-15.0] minutes in the normal psoas group). No permanent motor injuries occurred in either group, and no differences in length of stay or preoperative or postoperative Oswestry Disability Index scores were found between the groups. The protocol for L4/5 LLIF in patients with transitional psoas anatomy is described.

CONCLUSIONS

Transitional psoas anatomy is frequently encountered in surgical candidates for L4/5 LLIF. Through careful identification of the lumbar plexus and judicious retraction, the transpsoas LLIF can safely be performed in these patients.

Trends in lumbar spinal fusion-a literature review

Over the past several decades, there has been an upward trend in the total number of spinal fusion procedures worldwide. Advanced spinal fusion techniques with or without internal fixation, additional innovations in surgical approaches, innovative implants including a wide variety of interbody devices, and new alternatives in bone grafting materials are some reasons for the increasing number of spine fusion procedures. Moreover, the indications for spinal fusion have broadened over time. Initially developed for the treatment of instability and deformity due to tuberculosis, scoliosis, and traumatic injury, spinal fusion surgery has now a wide range of indications like spondylolisthesis, congenital or degenerative deformity, spinal tumors, and pseudarthrosis, with degenerative disorders as the most common indication. This review emphasizes current lumbar fusion techniques and their development in the past decades.

TRANSFORAMINAL INTERSOMATIC LUMBAR ARTHRODESIS: COMPARISON BETWEEN AUTOGRAFT AND CAGE IN PEEK

OBJECTIVE

To compare the postoperative outcomes of transforaminal intersomatic lumbar arthrodesis with structured iliac bone autograft and PEEK device.

METHODS

The total of 93 medical records of patients undergoing transforaminal intersomatic fusion between January 2012 and July 2017 with at least 1 year of postoperative follow-up, with complete medical record, containing clinical file and radiological exams, were reviewed.

RESULTS

From the medical records evaluated, 48 patients underwent the procedure with structured iliac autograft (group 1) and 45 with PEEK device (group 2). There was an improvement in functional capacity in both groups (p < 0.001), however there was no difference when comparing them (p = 0.591).

CONCLUSION

The postoperative clinical and radiological results of lumbar arthrodesis with TLIF technique, using a structured iliac bone autograft compared to a PEEK device, were similar. Level of Evidence II, Retrospective study.

Defining a safe working zone for lateral lumbar interbody fusion: a radiographic, cross-sectional study

PURPOSE

To present a radiographic analysis of the anatomy of the lumbar plexus and retroperitoneal blood vessels with respect to psoas morphology and safe working zones (SWZ) for LLIF.

METHODS

A retrospective radiographic analysis of 158 MRI scans was performed. Selected morphometric measurements were performed at L1-L2, L2-L3, L3-L4 and L4-L5 levels: disc anteroposterior distance, psoas anteroposterior distance, lumbar plexus-anterior disc distance, lumbar plexus-anterior psoas distance, vena cava-anterior disc distance and calculation of SWZ in psoas on both left and right sides. The morphometric measurements were analysed for differences with sex and the level.

RESULTS

All the morphometric parameters differed significantly at all levels between males and females. The SWZ was significantly wider on the left side compared to the right-at L2-L3, L3-L4 and L4-L5 levels in females and at L3-L4 and L4-L5 levels in males. The SWZ at L4-L5 was narrowest on both left and right sides-and significantly reduced compared to other levels. 6.9% patients had a SWZ > 20 mm on the left side, and 44.9% patients had SWZ < 20 mm on the right side. With caudal progression of levels, the lumbar plexus and psoas muscle migrated anteriorly and the vena cava/right iliac vein migrated posteriorly.

CONCLUSION

A detailed study of preoperative MRI scans should be carried out in patients planned for LLIF-particularly, at L4-L5 level and in females. A left-sided trans-psoas approach is safer to perform compared to the right side-a right-sided approach should be avoided at L4-L5 considering the narrow SWZ at that level.

The correlation of intraoperative distraction of intervertebral disc with the postoperative canal and foramen expansion following oblique lumbar interbody fusion

PURPOSE

To examine the correlation of intraoperative distraction of intervertebral disc with the postoperative central canal and foramen expansion by oblique lumbar interbody fusion (OLIF) with indirect decompression.

METHODS

Patients who underwent OLIF between October 2013 and April 2017 were included. Clinical outcomes included back and leg pain evaluated by visual analog scale (VAS) and Oswestry Disability Index (ODI). Intraoperative radiographic parameters of height ratio [(HR) = disc height/intervertebral body height)] and cage location were evaluated on intraoperative fluoroscopic images. Disc height (DH), foraminal height (FH), cross-sectional area of spinal canal (CSAC), and CSA of the foramen (CSAF) were measured.

RESULTS

A total of 47 patients involving 62 levels were enrolled in this study. Mean follow-up was 43.8 ± 12.0 months. These patients reported an improvement of 61.7% in VAS back, 68.1% in VAS leg, and 46% in ODI (all p < 0.01). Radiographic parameters including HR, DH, FH, CSAC, and CSAF were also significantly increased by 32.6%, 48.2%, 21.4%, 44.0%, and 40.1% (left-side CSAF) or 45.4% (right-side CSAF), respectively (p < 0.05). HR increment was correlated with CSA (canal and foramen) increment. Slightly higher improvements of HR, DH, FH, CSAC, and CSAF (both sides) were noted when cage was located at middle rather than anterior (p > 0.05).

CONCLUSIONS

The ligamentotaxis effect of OLIF is capable of supporting indirect decompression of central canal and neural foramina and clinical improvement. HR is a reliable intraoperative assessment method. In addition, intraoperative HR increment was correlated with postoperative neural elements expansion.

Lateral Lumbar Interbody Fusion: Review of Surgical Technique and Postoperative Multimodality Imaging Findings

The lateral lumbar interbody fusion (LLIF) approach is a minimally invasive surgery that can be used as an alternative to traditional lumbar interbody fusion techniques. LLIF accesses the intervertebral disk through the retroperitoneum and psoas muscle to avoid major vessels and visceral organs. The exposure of retroperitoneal structures during LLIF leads to unique complications compared with other surgical approaches. An understanding of the surgical technique and its associated potential complications is necessary for radiologists who interpret imaging before and after LLIF. Preoperative imaging must carefully assess the location of anatomic structures, including major retroperitoneal vasculature, lumbar nerve roots, lumbosacral plexus, and the genitofemoral nerve, relative to the psoas muscle. Multiple imaging modalities can be used in postoperative assessment including radiographs, CT, CT myelography, and MRI. Of these, CT is the preferred modality, because it can assess a range of complications relating to both the retroperitoneal exposure and the spinal instrumentation, as well as bone integrity and fusion status. This article describes surgical approaches for lumbar interbody fusion, comparing the approaches' indications, contraindications, advantages, and disadvantages; reviews the surgical technique of LLIF and relevant anatomic considerations; and illustrates for interpreting radiologists the normal postoperative findings and potential postsurgical complications of LLIF.

Prone Lateral Lumbar Interbody Fusion: Case Report and Technical Note

OBJECTIVE

The transpsoas lateral lumbar interbody fusion (LLIF) is a commonly used technique to manage various spinal conditions. LLIF is often performed in combination with posterior lumbar instrumentation, which requires patient repositioning or staging of the procedure. Here we present a step-by-step detailed description of a prone LLIF using an intraoperative laser level to guide orthogonal insertion of instrumentation.

METHODS

A 57-year-old man with history of L4-S1 instrumentation, who developed symptomatic adjacent L3L/4 level stenosis and sagittal plane imbalance. The single position prone lateral lumbar interbody fusion with posterior fixation was chosen in order to minimize operative room time and optimize lumbar lordosis (LL) correction.

RESULTS

The patient was positioned prone on a Jackson table. This position allowed for improved LL correction. A self-leveling laser line ensured ideal orthogonal use of instrumentation. The patient had improvement of symptoms immediately postoperatively and was discharged home on postoperative day 2 without complications.

CONCLUSIONS

The single position prone LLIF with posterior fixation offers a shorter operative room time by eliminating necessity to reposition the patient between stages of operation. The prone position of the patient optimizes LL correction. Further experience with this approach will allow for refining of the technique to overcome its limitations and facilitate its utilization.

Analysis of risk factors for perioperative hidden blood loss in patients undergoing transforaminal lumbar interbody fusion

Objective

This study was performed to analyze the correlation between perioperative hidden blood loss (HBL) and the general condition of patients undergoing transforaminal lumbar interbody fusion (TLIF).

Methods

We retrospectively analyzed patients who underwent TLIF from July 2017 to July 2019 in our hospital. Sex, age, body mass index, underlying diseases, American Society of Anesthesiologists classification, coagulation function, preoperative and postoperative hemoglobin level and hematocrit, surgery time, fusion level, intraoperative blood loss, and drainage volume were recorded. Postoperative complications were also recorded. The amount of HBL was calculated, and its correlation with related variables was analyzed.

Results

The mean surgery time was 153.32 ± 54.86 minutes. The total perioperative blood loss was 789.22 ± 499.68 mL, including HBL of 315.69 ± 199.87 mL. Pearson correlation analysis showed statistically significant differences in HBL according to the body mass index, hypertension, fibrinogen, surgery time, and fusion level. Multiple linear regression analysis indicated that the surgery time and fusion level were independent risk factors for HBL.

Conclusions

A certain amount of HBL occurs in TLIF surgery and cannot be ignored in daily clinical work. The operation time and surgery level are independent risk factors for HBL.

Percutaneous CT-guided lumbar trans-facet pedicle screw fixation in lumbar microinstability syndrome: feasibility of a novel approach

STUDY DESIGN

Prospective experimental uncontrolled trial.

BACKGROUND

Lumbar microinstability (MI) is a common cause of lower back pain (LBP) and is related to intervertebral disc degeneration that leads to inability to adequately absorb applied loads. The term "microinstability" has recently been introduced to denote a specific syndrome of biomechanical dysfunction with minimal anatomical change. Trans-facet fixation (TFF) is a minimally invasive technique that involves the placement of screws across the facet joint and into the pedicle, to attain improved stability in the spine.

PURPOSE

In this study, we aimed to evaluate the effectiveness, in terms of pain and disability reduction, of a stand-alone TFF in treatment of patients with chronic low back pain (LBP) due to MI. Moreover, as a secondary endpoint, the purpose was to assess the feasibility and safety of a novel percutaneous CT-guided technique.

METHODS

We performed percutaneous CT-guided TFF in 84 consecutive patients presenting with chronic LBP attributable to MI at a single lumbar level without spondylolysis. Pre- and post-procedure pain and disability levels were measured using the visual analogue scale (VAS) and Oswestry Disability Index (ODI).

RESULTS

At 2 years, TFF resulted in significant reductions in both VAS and ODI scores. CT-guided procedures were tolerated well by all patients under light sedation with a mean procedural time of 45 min, and there were no reported immediate or delayed procedural complications.

CONCLUSION

TFF seems to be a powerful technique for lumbar spine stabilization in patients with chronic mechanical LBP related to lumbar MI. CT-guided technique is fast, precise, and safe and can be performed in simple analgo-sedation.

Full Percutaneous Treatment of Degenerative Disc Disease with Intradiscal Lumbar Interbody Fusion and Posterior Stabilization: Preliminary Results

PURPOSE

To report the preliminary results of a novel full percutaneous interbody fusion technique for the treatment of degenerative disc disease (DDD) resistant to conservative treatment with posterior stabilization with rods and screws and transforaminal placement of an 8-mm-width intradiscal cage.

MATERIALS AND METHODS

A total of 79 patients with lumbar spine DDD resistant to medical therapy and/or spondylolisthesis up to grade 2 were treated. We performed preoperative X-rays, CT and MRI. The outcomes were assessed using the VAS score and the Oswestry Disability Index at a 1-, 6- and 12-month follow-up and also included X-rays to evaluate the correct bone fusion and the absence of complications.

RESULTS

Mean operation time was 130 min, and mean postoperative time until hospital discharge was 2 days. Postoperative values for VAS scores and ODI improved significantly compared to preoperative data: Mean preprocedural VAS was 7.49 ± 0.69 and decreased at 12-month follow-up to 1.31 ± 0.72, and mean preprocedural ODI was 29.94 ± 1.67 and decreased at 12-month follow-up to 12.75 ± 1.44. No poor results were reported, and no postprocedural sequelae were observed.

CONCLUSIONS

In our experience, this preliminary report shows a feasible and safe full percutaneous alternative procedure and represents a minimally invasive management of degenerative disc disease with low back pain resistant to medical therapy with or without lumbar spondylolisthesis up to grade 2.

Cortical bone trajectory instrumentation provides favorable perioperative outcomes compared to pedicle screws for single-level lumbar spinal stenosis and degenerative spondylolisthesis

Objective

To compare perioperative outcomes between cortical bone trajectory (CBT) instrumentation with pedicle screws (PS) in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis.

Methods

A consecutive series of 91 patients from a single institution between January 2017 and July 2019 were retrospectively reviewed.

Results

Patients in CBT group had significantly shorter operative time, lower blood loss and shorter length of stay.

Conclusion

CBT instrumentation demonstrated favorable perioperative outcomes that may enhance the overall value in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis.

Numerical simulation of lateral and transforaminal lumbar interbody fusion, two minimally invasive surgical approaches

The present study aims to compare spinal stability after two different minimally invasive techniques, the lateral lumbar interbody fusion (LLIF) and the transforaminal lumbar interbody fusion (TLIF) approaches. Two nonlinear three-dimensional finite element (FE) models of the L4-L5 functional spinal unit (FSU) were subjected to the loads that usually act on the lumbar spine. Findings show that the LLIF approach yields better results for torsion load case, due to the larger surface area of the implant. For extension, flexion and lateral bending loads, the TLIF approach presents smaller displacements probably due to the anterior placement of the cage and to the smaller damaged area of the annulus fibrosus.

Open versus minimally invasive TLIF: literature review and meta-analysis

Study design

This study is a comparative, literature review.

Objective

The aim of this study is to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review and a meta-analysis.

Summary of background data

Lumbar interbody fusion is a well-established surgical procedure for treating several spinal disorders. Transforaminal lumbar interbody fusion (TLIF) was initially introduced in the early 1980s. To reduce approach-related morbidity associated with traditional open TLIF (OTLIF), minimally invasive TLIF (MITLIF) was developed. We aimed to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review.

Methods

We searched the online database PubMed (2005–2017), which yielded an initial 194 studies. We first searched the articles’ abstracts. Based on our inclusion criteria, we excluded 162 studies and included 32 studies: 18 prospective, 13 retrospective, and a single randomized controlled trial. Operative time, blood loss, length of hospital stay, radiation exposure time, complication rate, and pain scores (visual analogue scale, Oswestry Disability Index) for both techniques were recorded and presented as means. We then performed a meta-analysis.

Results

The meta-analysis for all outcomes showed reduced blood loss (P < 0.00001) and length of hospital stay (P < 0.00001) for MITLIF compared with OTLIF, but with increased radiation exposure time with MITLIF (P < 0.00001). There was no significant difference in operative time between techniques (P = 0.78). The complication rate was lower with MITLIF (11.3%) vs. OTLIF (14.2%), but not statistically significantly different (P = 0.05). No significant differences were found in visual analogue scores (back and leg) and Oswestry Disability Index scores between techniques, at the final follow-up.

Conclusion

MITLIF and OTLIF provide equivalent long-term clinical outcomes. MITLIF had less tissue injury, blood loss, and length of hospital stay. MITLIF is also a safe alternative in obese patients and, in experienced hands, can also be used safely in select cases of spondylodiscitis even with epidural abscess. MITLIF is also a cost-saving procedure associated with reduced hospital and social costs. Long-term studies are required to better evaluate controversial items such as operative time.

Anatomic Considerations in the Lateral Transpsoas Interbody Fusion: The Impact of Age, Sex, BMI, and Scoliosis

STUDY DESIGN

This is a retrospective case series.

OBJECTIVE

Define the anatomic variations and the risk factors for such within the operative corridor of the transpsoas lateral interbody fusion.

SUMMARY OF BACKGROUND DATA

The lateral interbody fusion approach has recently been associated with devastating complications such as injury to the lumbosacral plexus, surrounding vasculature, and bowel. A more comprehensive understanding of anatomic structures in relation to this approach using preoperative imaging would help surgeons identify high-risk patients potentially minimizing these complications.

MATERIALS AND METHODS

Age-sex distributed, naive lumbar spine magnetic resonance imagings (n=180) were used to identify the corridor for the lateral lumbar interbody approach using axial images. Bilateral measurements were taken from L1-S1 to determine the locations of critical vascular, intraperitoneal, and muscular structures. In addition, a subcohort of scoliosis patients (n=39) with a Cobb angle >10 degrees were identified and compared.

RESULTS

Right-sided vascular anatomy was significantly more variant than left (9.9% vs. 5.7%; P=0.001). There were 9 instances of "at-risk" vasculature on the right side compared with 0 on the left (P=0.004). Age increased vascular anatomy variance bilaterally, particularly in the more caudal levels (P≤0.001). A "rising-psoas sign" was observed in 26.1% of patients. Bowel was identified within the corridor in 30.5% of patients and correlated positively with body mass index (P<0.001). Scoliosis increased variant anatomy of left-sided vasculature at L2-3/L3-4. Nearly all variant anatomy in this group was found on the convex side of the curvature (94.2%).

CONCLUSIONS

Given the risks and complications associated with this approach, careful planning must be taken with an understanding of vulnerable anatomic structures. Our analysis suggests that approaching the intervertebral space from the patient's left may reduce the risk of encountering critical vascular structures. Similarly, in the setting of scoliosis, an approach toward the concave side may have a more predictable course for surrounding anatomy.

LEVEL OF EVIDENCE

Level 3-study.

The Modified 5-Item Frailty Index: A Concise and Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity Following Elective Posterior Lumbar Fusions

BACKGROUND

The modified 5-item frailty index (mFI-5) is a concise comorbidity-based risk stratification tool that has been shown to predict the occurrence of adverse outcomes following various orthopedic surgeries.

METHODS

The 2012-2016 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing an elective 1- to 2-level posterior lumbar fusion for degenerative lumbar pathology. The mFI-5 score was calculated based on the presence of the 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on postoperative morbidity while controlling for baseline clinical characteristics.

RESULTS

Increasing mFI-5 score versus mFI-5 = 0 was associated with higher odds of any complication (mFI-5 ≥2: odds ratio [OR] 1.45; mFI-5 = 1: OR 1.22), 30-day readmissions (mFI-5 ≥2: OR 1.46; mFI-5 = 1: OR 1.18), and nonhome discharge (mFI-5 ≥2: OR 1.80; mFI-5 = 1: OR 1.16). Higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, unplanned reoperation, any medical complication, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, bleeding requiring transfusion, sepsis, and septic shock.

CONCLUSIONS

Higher mFI-5 scores were associated with increased postoperative morbidity following elective 1- to 2-level posterior lumbar fusions.

Approach-based Comparative and Predictor Analysis of 30-day Readmission, Reoperation, and Morbidity in Patients Undergoing Lumbar Interbody Fusion Using the ACS-NSQIP Dataset

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the difference in 30-day readmission, reoperation, and morbidity for patients undergoing either posterior or anterior lumbar interbody fusion.

SUMMARY OF BACKGROUND DATA

Despite increasing utilization of lumbar interbody fusion to treat spinal pathology, few studies compare outcomes by surgical approach, particularly using large nationally represented cohorts.

METHODS

Patients who underwent lumbar interbody fusion were identified using the NSQIP database. Rates of readmission, reoperation, morbidity, and associated predictors were compared between posterior/transforaminal (PLIF/TLIF) and anterior/lateral (ALIF/LLIF) lumbar interbody fusion using multivariate regression. Bonferroni-adjusted alpha-levels were utilized whereby variables were significant if their P values were less than the alpha-level or trending if their P values were between 0.05 and the alpha-level.

RESULTS

We identified 26,336 patients. PLIF/TLIF had greater operative time (P = 0.015), transfusion (P < 0.001), UTI (P = 0.008), and stroke/CVA (P = 0.026), but lower prolonged ventilation (P < 0.001) and DVT (P = 0.002) rates than ALIF/LLIF. PLIF/TLIF independently predicted greater morbidity on multivariate analysis (odds ratio: 1.155, P = 0.0019).In both groups, experiencing a complication and, in PLIF/TLIF, ASA-class ≥3 predicted readmission (P < 0.001). Increased age trended toward readmission in ALIF/LLIF (P = 0.003); increased white cell count (P = 0.003), dyspnea (P = 0.030), and COPD (P = 0.005) trended in PLIF/TLIF. In both groups, increased hospital stay and wound/site-related complication predicted reoperation (P < 0.001). Adjunctive posterolateral fusion predicted reduced reoperation in ALIF/LLIF (P = 0.0018). ASA-class ≥3 (P = 0.016) and age (P = 0.021) trended toward reoperation in PLIF/TLIF and ALIF/LLIF, respectively. In both groups, age, hospital stay, reduced hematocrit, dyspnea, ASA-class ≥3, posterolateral fusion, and revision surgery and, in PLIF/TLIF, bleeding disorder predicted morbidity (P < 0.001). Female sex (P = 0.010), diabetes (P = 0.042), COPD (P = 0.011), and disseminated cancer (P = 0.032) trended toward morbidity in PLIF/TLIF; obesity trended in PLIF/TLIF (P = 0.0022) and ALIF/LLIF (P = 0.020).

CONCLUSION

PLIF/TLIF was associated with a 15.5% increased odds of morbidity; readmission and reoperation were similar between approaches. Older age, higher ASA-class, and specific comorbidities predicted poorer 30-day outcomes, while procedural-related factors predicted only morbidity. These findings can guide surgical approach given specific factors.

LEVEL OF EVIDENCE

3.

The Effects of Chronic Preoperative Steroid Therapy on Perioperative Complications Following Elective Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Chronic steroid therapy is used in the treatment of various inflammatory and autoimmune conditions, but it is known to be associated with adverse effects. There remains a gap in the literature regarding the role of chronic steroid therapy in predisposing patients to perioperative complications following elective posterior lumbar fusion (PLF). We aimed to identify the effects of chronic preoperative steroid therapy on 30-day perioperative complications in patients undergoing PLF.

METHODS

A retrospective analysis was performed using the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. We identified 22 903 patients who underwent elective PLF. There were 849 patients (3.7%) who received chronic preoperative steroid therapy. Univariate and multivariate analyses were performed to examine steroid therapy as an independent risk factor for 30-day perioperative complications. A subgroup analysis of patients on chronic steroid therapy was then performed to identify additional patient characteristics that further increased the risk for perioperative complications.

RESULTS

Chronic preoperative steroid therapy was an independent risk factor for 7 perioperative complications, including superficial surgical site infection (SSI), deep SSI, wound dehiscence, urinary tract infection, pulmonary embolism, nonhome discharge, and readmission. Subgroup analysis demonstrated that morbid obesity further predisposed patients on chronic steroid therapy to an increased risk of superficial SSI and wound dehiscence.

CONCLUSIONS

Patients on chronic preoperative steroid therapy are at increased risk of multiple perioperative complications following elective PLF, particularly surgical site complications and venous thromboembolic events. This risk is further elevated in patients who are morbidly obese.

Selective Anterior Lumbar Interbody Fusion for Low Back Pain Associated With Degenerative Disc Disease Versus Nonsurgical Management

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To evaluate the long-term outcomes of selective one- to two-level anterior lumbar interbody fusions (ALIFs) in the lower lumbar spine versus continued nonsurgical management.

SUMMARY OF BACKGROUND DATA

Low back pain associated with lumbar intervertebral disc degeneration is common with substantial economic impact, yet treatment remains controversial. Surgical fusion has previously provided mixed results with limited durable improvement of pain and function.

METHODS

Seventy-five patients with one or two levels of symptomatic Pfirrmann grades 3 to 5 disc degeneration from L3-S1 were identified. All patients had failed at least 6 months of nonsurgical treatment. Forty-two patients underwent one- or two-level ALIFs; 33 continued multimodal nonsurgical care. Patients were evaluated radiographically and the visual analog pain scale (VAS), Oswestry Disability Index (ODI), EuroQol five dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System scores for pain interference, pain intensity, and anxiety. As-treated analysis was performed to evaluate outcomes at a mean follow-up of 7.4 years (range: 2.5-12).

RESULTS

There were no differences in pretreatment demographics or nonsurgical therapy utilization between study arms. At final follow-up, the surgical arm demonstrated lower VAS, ODI, EQ-5D, and Patient-Reported Outcomes Measurement Information System pain intensity scores versus the nonsurgical arm. VAS and ODI scores improved 52.3% and 51.1% in the surgical arm, respectively, versus 15.8% and -0.8% in the nonsurgical arm. Single-level fusions demonstrated improved outcomes versus two-level fusions. The pseudarthrosis rate was 6.5%, with one patient undergoing reoperation. Asymptomatic adjacent segment degeneration was identified in 11.9% of patients.

CONCLUSION

Selective ALIF limited to one or two levels in the lower lumbar spine provided improved pain and function when compared with continued nonsurgical care. ALIF may be a safe and effective treatment for low back pain associated with disc degeneration in select patients who fail nonsurgical management.

LEVEL OF EVIDENCE

3.

Biomechanics of an Expandable Lumbar Interbody Fusion Cage Deployed Through Transforaminal Approach

Background

A novel expandable lumbar interbody fusion cage has been developed which allows for a broad endplate footprint similar to an anterior lumbar interbody fusion; however, it is deployed from a minimally invasive transforaminal unilateral approach. The perceived benefit is a stable circumferential fusion from a single approach that maintains the anterior tension band of the anterior longitudinal ligament. The purpose of this biomechanics laboratory study was to evaluate the biomechanical stability of an expandable lumbar interbody cage inserted using a transforaminal approach and deployed in situ compared to a traditional lumbar interbody cage inserted using an anterior approach (control device).

Methods

Twelve cadaveric spine specimens (L1-5) were tested intact and after implantation of both the control and experimental devices in 2 (L2-3 and L3-4) segments of each specimen; the assignments of the control and experimental devices to these segments were alternated. Effect of supplemental pedicle screw-rod stabilization was also assessed. Moments were applied to the specimens in flexionextension (FE), lateral bending (LB), and axial rotation (AR). The effect of physiologic preload on construct stability was evaluated in FE. Segmental motions were measured using an optoelectronic motion measurement system.

Results

The deployable expendable transforaminal lumbar interbody fusion (TLIF) cage and control devices significantly reduced FE motion with and without compressive preload when compared to the intact condition (P < .05). Segmental motions in LB and AR were also significantly reduced with both devices (P < .05). Under no preload, the deployable expendable TLIF cage construct resulted in significantly smaller FE motion compared to the control cage construct (P < .01). Under all other testing modes (FE under 400N preload, LB, and AR), the postoperative motions of the 2 constructs did not differ statistically (P > .05). Adding bilateral pedicle screws resulted in further reduction of range of motion for all loading modes compared to intact condition, with no statistical difference between the 2 constructs (P > .05).

Conclusions

The ability of the deployable expendable interbody cage in reducing segmental motions was equivalent to the control cage when used as a standalone construct and also when supplemented with bilateral pedicle screw-rod instrumentation. The larger footprint of the fully deployed TLIF cage combined with preservation of the anterior soft-tissue tension band may provide a better biomechanical fusion environment by combining the advantages of the traditional anterior lumbar interbody fusion and TLIF approaches.

A UK-based pilot study of current surgical practice and implant preferences in lumbar fusion surgery

Lumbar fusion surgery is an established procedure for the treatment of low back pain. Despite the wide set of alternative fusion techniques and existing devices, uniform guidelines are not available yet and common surgical trends are scarcely investigated.The purpose of this UK-based study was to provide a descriptive portrait of current surgeons' practice and implant preferences in lumbar fusion surgery.A UK-based in-person survey was designed for this study and submitted to a group of consultant spinal surgeons (n = 32). Fifteeen queries were addressed based on different aspects of surgeons' practice: lumbar fusion techniques, implant preferences, and bone grafting procedures. Answers were analyzed by means of descriptive statistics.Thirty-two consultant spinal surgeons completed the survey. There was clear consistency on the relevance of a patient-centered management (82.3%), along with a considerable variability of practice on the preferred fusion approach. Fixation surgery was found to be largely adopted (96.0%) and favored over stand-alone cages. With regards to the materials, titanium cages were the most used (54.3%). The geometry of the implants influenced the choice of lumbar cages (81.3%). Specifically, parallel-shape cages were mostly avoided (89.2%) and hyperlordotic cages were preferred at the lower lumbar levels. However, there was no design for lumbar cages which was consistently favored. Autograft bone graft surgeries were the most common (60.0%). Amongst the synthetic options, hydroxyapatite-based bone graft substitutes (76.7%) in injectable paste form (80.8%) were preferred.Current lumbar fusion practice is variable and patient-oriented. Findings from this study highlight the need for large-scale investigative surveys and clinical studies aimed to set specific guidelines for certain pathologies or patient categories.

A psoas splitting approach developed for outpatient lateral interbody fusion versus a standard transpsoas approach

Background

The technique of transpsoas lateral interbody fusion has been adopted to avoid direct anterior interbody fusion, but lateral fusions have been limited to disc spaces above L5 and are associated with neurologic injuries especially to the lumbar plexus when approaching L4-5. The authors aim to demonstrate a psoas splitting technique to decrease risk of complications associated with the standard transpsoas technique.

Methods

Medical records of 84 patients with prospectively collected data reviewed. Two groups created 44 patients with standard lateral transpsoas approach (group 1) and 40 patients with psoas splitting approach (group 2). The psoas splitting approach utilizes two blades placed anteriorly and posteriorly to split the psoas fibers anteriorly while keeping the posterior blade docked in place where it enters the psoas muscle. The cephalocaudal blades sit above the psoas muscle measuring 30-40 mm shorter than the posterior docking blade.

Results

Thirty-nine males and 45 females, age range 31-71 years, average 58±2 years. Average body mass index (BMI) was 28.4±1.1 kg/m². Mean preoperative standard approach Oswestry disability index (ODI) increased from 48.4±3.0 to 55.2±4.0 compared to psoas splitting approach preoperative ODI means reduced from 45.1±5.0 to 34.9±6.0 (P=0.010). Group 1 mean preoperative visual analogue scale (VAS) score improved from 7.8±0.3 to 3.8±0.6 compared to group 2 mean preoperative VAS score which improved from 7.2±0.4 to 2.7±0.5 (P=0.048). Major complication rate of 20.5% was noted in standard transpsoas approach patients, including inability to walk and dermatome numbness.

Conclusions

The outcomes of this study have shown that patients who had lateral lumbar interbody fusion (LLIF) with the psoas splitting approach had statistically significant improvement in ODI scores compared to the standard approach. Fusion was achieved in all patients and there was no evidence of implant failure or subsidence. In the psoas splitting group the major complication rate was only 5%.

Elastomeric Lumbar Total Disc Replacement: Clinical and Radiological Results With Minimum 84 Months Follow-Up

BACKGROUND

Total lumbar disc replacement (TDR) devices have been designed to maintain motion, but both biomechanical and clinical data have indicated that a more controlled motion and additional load absorption in TDR would be beneficial. This work analyzed long-term results of an elastomeric disc (Physio-L) for degenerative lumbar conditions.

MATERIAL AND METHODS

This was a prospective, noncomparative, single-center clinical and radiological study. A total of 15 patients with predominant low back pain due degenerative disc disease received anterior total disc replacement with a Physio-L disc. Clinical outcomes were assessed both with a visual analog scale for pain and Oswestry Disability Index questionnaires. Radiological outcomes included implant failure, range of motion (ROM), facet degeneration, and adjacent level disease. Complication and reoperation rates were also recorded. The cases were assessed with a minimum follow-up of 84 months.

RESULTS

A total of 15 patients were enrolled (20 TDRs)-10 single-level cases (L5S1) and 5 two-level cases (L4L5/L5S1). After 84 months, clinical outcomes scores still demonstrated significant improvement compared with baseline (P < .001). Mean visual analog scale scores dropped from 7.1 to 2.9, and the Oswestry Disability Index improved from 50 to 16. No disc has experienced migration or breakage. The average range of motion value went from a baseline of 12.0° to 13.3° at 12 months, and at the final follow-up it decreased to 9.9°. Regarding the double-level cases, 3 of 5 (60%) had adverse events; just 1 single-level (10%) had adverse events. At final follow-up, radiological signs of facet degeneration were present in 7 of 15 patients (47%) but with only 1 of 15 (6.7%) symptomatic. Two patients (13%) required surgery at the adjacent level. At the 84-month follow-up, 16 of 18 prostheses (89%) were still active (2 revised to fusion and 2 were lost to follow-up).

CONCLUSION

The long-term follow-up data shows satisfactory clinical results for the use of Physio-L elastomeric TDR in the treatment of degenerative disc disease. Studies with bigger cohorts are needed to replicate results and add new information regarding other details.

Nerve Root and Lumbar Plexus Proximity to Different Extraforaminal Lumbar Interbody Fusion Trajectories: A Cadaver Study

STUDY DESIGN

Cadaver study.

OBJECTIVE

To investigate the safety of the extraforaminal lumbar interbody fusion approach.

SUMMARY OF BACKGROUND DATA

Over the last decade the number of techniques available for lumbar interbody fusion has increased. Recent interest has developed in an extraforaminal approach to the intervertebral disc to reduce the morbidity associated with facetectomy. The safety of this extraforaminal corridor with regards to the exiting nerve root and lumbar plexus has yet to be assessed.

METHODS

With the cadaver prone, the C-arm was positioned over the disc of interest and aligned perpendicular to the superior endplate of the inferior vertebral body, with the superior articular process bisecting the available disc space. Three needles were passed into the disc and labeled medial, middle, and lateral. After needle placement, each nerve root and the lumbar plexus were dissected. The distance of each needle to these structures was measured and discectomy was performed to assess potential graft length from a transforaminal and extraforaminal approach.

RESULTS

We performed the method on levels L1-L5 bilaterally on 2 cadavers, totaling 16 attempts for each needle position. The average distance to nerve of the medial approach (3.2±1.1 mm) was statistically greater than both the middle (1.1±1.4 mm) and lateral (-0.2±2.9 mm) approaches (P<0.0001 for both). The distance to plexus of the medial approach (14.3±6.2 mm) was greater than the middle (9.2±6.1 mm) approach and statistically greater than the lateral (5.2±5.6 mm) approach (P=0.001). There was a greater graft length available by the extraforaminal lumbar interbody fusion approach (36.1±2.7 mm) than the transforaminal lumbar interbody fusion approach (29.3±3.5 mm, P<0.0001).

CONCLUSIONS

The safest trajectory was the medial, passing adjacent to the superior articular process. The close proximity, however, means that neuromonitoring and tubular dilators would be necessary to use this technique in a clinical setting.

LEVEL

Level V.

Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation: A Retrospective Study With 2-year Follow-up

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to evaluate the clinical and radiological outcomes of mini-open ALIF (MO-ALIF) with self-anchored stand-alone cages for the treatment of lumbar disc herniation in comparison with transforaminal lumbar interbody fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

METHODS

This study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n = 42) or TLIF (n = 40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

RESULTS

Patients who underwent TLIF had a significantly higher volume of blood loss (295.2 ± 81.4 vs. 57.0 ± 15.2 mL) and longer surgery time (130.7 ± 45.1 vs. 60.4 ± 20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group.

CONCLUSION

MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

LEVEL OF EVIDENCE

3.

Biomechanics of an Expandable Lumbar Interbody Fusion Cage Deployed Through Transforaminal Approach

Introduction

A novel expandable lumbar interbody fusion cage has been developed which allows for a broad endplate footprint similar to an anterior lumbar interbody fusion (ALIF); however, it is deployed from a minimally invasive transforaminal unilateral approach. The perceived benefit is a stable circumferential fusion from a single approach that maintains the anterior tension band of the anterior longitudinal ligament.The purpose of this biomechanics laboratory study was to evaluate the biomechanical stability of an expandable lumbar interbody cage inserted using a transforaminal approach and deployed in situ compared to a traditional lumbar interbody cage inserted using an anterior approach (control device).

Methods

Twelve cadaveric spine specimens (L1-L5) were tested intact and after implantation of both the control and experimental devices in two (L2-L3 and L3-L4) segments of each specimen; the assignments of the control and experimental devices to these segments were alternated. Effect of supplemental pedicle screw-rod stabilization was also assessed. Moments were applied to the specimens in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). The effect of physiologic preload on construct stability was evaluated in FE. Segmental motions were measured using an optoelectronic motion measurement system.

Results

The deployable expendable TLIF cage and control devices significantly reduced FE motion with and without compressive preload when compared to the intact condition (p<0.05). Segmental motions in LB and AR were also significantly reduced with both devices (p<0.05). Under no preload, the deployable expendable TLIF cage construct resulted in significantly smaller FE motion compared to the control cage construct (p<0.01). Under all other testing modes (FE under 400N preload, LB, and AR) the postoperative motions of the two constructs did not differ statistically (p>0.05). Adding bilateral pedicle screws resulted in further reduction of ROM for all loading modes compared to intact condition, with no statistical difference between the two constructs (p>0.05).

Conclusions

The ability of the deployable expendable interbody cage in reducing segmental motions was equivalent to the control cage when used as a stand-alone construct and also when supplemented with bilateral pedicle screw-rod instrumentation. The larger footprint of the fully deployed TLIF cage combined with preservation of the anterior soft-tissue tension band may provide a better biomechanical fusion environment by combining the advantages of the traditional ALIF and TLIF approaches.

Cross-Sectional Area of the Lumbar Spine Trunk Muscle and Posterior Lumbar Interbody Fusion Rate: A Retrospective Study

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate the relationship between trunk muscle cross-sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion using pedicle screw fixation (PLIF-PSF).

SUMMARY OF BACKGROUND DATA

Although trunk muscles of the lumbar spine contribute to spinal stability and alignment, effect of trunk muscles on spinal fusion rate and time to fusion is unclear.

METHODS

A total of 192 adult patients with degenerative lumbar disease who underwent PLIF-PSF at L3-L4 or L4-L5 were included. The MCSA of the flexor (psoas major, PS), extensor (erector spinae, ES; multifidus, MF) were measured using preoperative lumbar magnetic resonance imaging at 3 segments. Bone union was evaluated using lumbar dynamic plain radiography. Patients were divided into 2 groups according to the presence of bone fusion.

RESULTS

Most PS MCSAs in the fusion group were significantly larger than in the nonfusion group, except for MCSA at the L2-L3 segment (all P<0.05). In cases of ES and MF MCSAs, 4 of 6 segments were significantly large. Multivariate analysis revealed that the PS MCSA at L4-L5 was an independent factor for decreased possibility of nonfusion status in both segments (OR=0.812, P=0.028). Pearson analysis demonstrated that the most trunk MCSAs were negatively correlated with time to fusion for both segments and PS MCSAs exhibited a significant correlation with time to fusion except for MCSA at the L2-L3 segment.

CONCLUSIONS

Trunk MCSAs were significantly larger for a fusion group than a nonfusion group. As trunk MCSAs increased, fusion timing decreased.

A Biomechanical Stability Study of Extraforaminal Lumbar Interbody Fusion on the Cadaveric Lumbar Spine Specimens

Background

Transforaminal lumbar interbody fusion (TLIF) is an effective surgery for lumbar degenerative disease. However, this fusion technique requires resection of inferior facet joint to provide access for superior facet joint resection, which results in reduced lumbar spinal stability and unnecessary trauma. We have previously developed extraforaminal lumbar interbody fusion (ELIF) that can avoid back muscle injury with direct nerve root decompression. This study aims to show that ELIF enhances lumbar spinal stability in comparison to TLIF by comparing lumbar spinal stability of L4–L5 range of motion (ROM) on 12 cadaveric spine specimens after performing TLIF or ELIF.

Methods

12 cadaveric spine specimens were randomly divided and treated in accordance with the different internal fixations, including ELIF with a unilateral pedicle screw (ELIF+UPS), TLIF with a unilateral pedicle screw (TLIF+UPS), TLIF with a bilateral pedicle screw (TLIF+BPS), ELIF with a unilateral pedicle screw and translaminar facet screw (ELIF+UPS+TLFS) and ELIF with a bilateral pedicle screw (ELIF+BPS). The treatment groups were exposed to a 400-N load and 6 N·m movement force to calculate the angular displacement of L4-L5 during anterior flexion, posterior extension, lateral flexion and rotation operation conditions.

Results

The ROM in ELIF+UPS group was smaller than that of TLIF+UPS group under all operating conditions, with the significant differences in left lateral flexion and right rotation by 36.15% and 25.97% respectively. The ROM in ELIF+UPS group was higher than that in TLIF+BPS group. The ROM in the ELIF+UPS+TLFS group was much smaller than that in the ELIF+UPS group, but was not significantly different than that in the TLIF+BPS group.

Conclusions

Despite that TLIF+BPS has great stability, which can be comparable by that of ELIF+UPS. Additionally, ELIF stability can be further improved by using translaminar facet screws without causing more tissue damage to patient.

A Narrative Review of Lumbar Fusion Surgery With Relevance to Chiropractic Practice

OBJECTIVE

The purpose of this narrative review was to describe the most common spinal fusion surgical procedures, address the clinical indications for lumbar fusion in degeneration cases, identify potential complications, and discuss their relevance to chiropractic management of patients after surgical fusion.

METHODS

The PubMed database was searched from the beginning of the record through March 31, 2015, for English language articles related to lumbar fusion or arthrodesis or both and their incidence, procedures, complications, and postoperative chiropractic cases. Articles were retrieved and evaluated for relevance. The bibliographies of selected articles were also reviewed.

RESULTS

The most typical lumbar fusion procedures are posterior lumbar interbody fusion, anterior lumbar interbody fusion, transforaminal interbody fusion, and lateral lumbar interbody fusion. Fair level evidence supports lumbar fusion procedures for degenerative spondylolisthesis with instability and for intractable low back pain that has failed conservative care. Complications and development of chronic pain after surgery is common, and these patients frequently present to chiropractic physicians. Several reports describe the potential benefit of chiropractic management with spinal manipulation, flexion-distraction manipulation, and manipulation under anesthesia for postfusion low back pain. There are no published experimental studies related specifically to chiropractic care of postfusion low back pain.

CONCLUSIONS

This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.