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Aguirre AO, Soliman MAR, Kuo CC, Kassay A, Parmar G, Kruk MD, Quiceno E, Khan A, Lim J, Hess RM, Mullin JP, Pollina J. Defining cage subsidence in anterior, oblique, and lateral lumbar spine fusion approaches: a systematic review of the literature. Neurosurg Rev 2024; 47:332. [PMID: 39009745 DOI: 10.1007/s10143-024-02551-5] [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: 01/05/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1%) reported on the ALIF approach, 22 (31.9%) on the OLIF approach, and 31 (44.9%) on the LLIF approach, 2 of which reported on more than one approach. ALIF articles most commonly calculated the loss of disc height over time with a subsidence threshold of > 2 mm. Most OLIF articles calculated the total amount of cage migration into the vertebral bodies, with a threshold of > 2 mm. LLIF was the only approach in which most articles applied the same method for calculation, namely, a grading scale for classifying the loss of disc height over time. We recommend future articles adhere to the most common methodologies presented here to ensure accuracy and generalizability in reporting cage subsidence.
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Affiliation(s)
- Alexander O Aguirre
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrea Kassay
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Gaganjot Parmar
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Marissa D Kruk
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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Mok JM, Forsthoefel C, Diaz RL, Lin Y, Amirouche F. Biomechanical Comparison of Unilateral and Bilateral Pedicle Screw Fixation after Multilevel Lumbar Lateral Interbody Fusion. Global Spine J 2024; 14:1524-1531. [PMID: 36583232 DOI: 10.1177/21925682221149392] [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: 12/31/2022] Open
Abstract
STUDY DESIGN Human Cadaveric Biomechanical Study. OBJECTIVES Lumbar Lateral Interbody Fusion (LLIF) utilizing a wide cage has been reported as having favorable biomechanical characteristics. We examine the biomechanical stability of unilateral pedicle screw and rod fixation after multilevel LLIF utilizing 26 mm wide cages compared to bilateral fixation. METHODS Eight human cadaveric specimens of L1-L5 were included. Specimens were attached to a universal testing machine (MTS 30/G). Three-dimensional specimen range of motion (ROM) was recorded using an optical motion-tracking device. Specimens were tested in 3 conditions: 1) intact, 2) L1-L5 LLIF (4 levels) with unilateral rod, 3) L1-L5 LLIF with bilateral rods. RESULTS From the intact condition, LLIF with unilateral rod decreased flexion-extension by 77%, lateral bending by 53%, and axial rotation by 26%. In LLIF with bilateral rods, flexion-extension decreased by 83%, lateral bending by 64%, and axial rotation by 34%. Comparing unilateral and bilateral fixation, LLIF with bilateral rods reduced ROM by a further 23% in flexion-extension, 25% in lateral bending, and 11% in axial rotation. The difference was statistically significant in flexion-extension and lateral bending (P < .005). CONCLUSIONS Considerable decreases in ROM were observed after multilevel (4-level) LLIF utilizing 26 mm cages supplemented with both unilateral and bilateral pedicle screws and rods. The addition of bilateral fixation provides a 10-25% additional decrease in ROM. These results can inform surgeons of the incremental biomechanical benefit when considering unilateral or bilateral posterior fixation after multilevel LLIF.
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Affiliation(s)
- James M Mok
- NorthShore University HealthSystem, Skokie, IL, USA
| | - Craig Forsthoefel
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ye Lin
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Farid Amirouche
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
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Shen S, You X, Ren Y, Ye S. Risk Factors of Cage Subsidence Following Oblique Lumbar Interbody Fusion: A Meta-analysis and Systematic Review. World Neurosurg 2024; 183:180-186. [PMID: 38145652 DOI: 10.1016/j.wneu.2023.12.110] [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: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVES The aim of this systematic review was to evaluate the risk factors for cage subsidence (CS) after oblique lumbar interbody fusion (OLIF). METHODS The cohort and case-control studies which reporting potential risk factors for CS following OLIF were searched in PubMed, Embase, and Web of Science from database inception to June 17, 2023. Two researchers independently screened the literature, extracted data, and evaluated the quality of the literature according to the Newcastle Ottawa Scale. RevMan5.3 software was used for Meta analysis. χ2 statistics and I2 statistics were used to evaluate heterogeneity, and the analysis results were represented by forest plots. RESULTS A total of 8 studies with 280 cases of CS from 832 patients who underwent OLIF met the inclusion criteria. Elderly patients over 60 years old (odds ratio [OR] 2.44, 95% CI 1.38-4.31, P = 0.002), osteoporosis (OR 4.18, 95% CI 2.30-7.61, P = 0.002), end plate injury (OR 5.72, 95% CI 2.32-14.11, P = 0.0002), and overdistraction of intervertebral space (OR 1.67, 95% CI 1.3 2-2.11, P < 0.0001) were potential risk factors, while Hounsfield units value of the vertebral body (OR 0.97, 95% CI 0.95-1.00, P = 0.02) is a protective factor. The number of operative segments did not increase the risk of CS. CONCLUSIONS Older age, osteoporosis, endplate injury, and overdistraction of the intervertebral space may increase the risk of CS after OLIF. Although the incidence rate of CS is low, implementing effective preventions is a priority for clinicians based on these risk factors.
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Affiliation(s)
- Shufeng Shen
- Department of Spinal Surgery, Yuyao People's Hospital, Zhejiang Province, China.
| | - Xinmao You
- Department of Spinal Surgery, Yuyao People's Hospital, Zhejiang Province, China
| | - Yingqing Ren
- Department of Spinal Surgery, Yuyao People's Hospital, Zhejiang Province, China
| | - Senqi Ye
- Department of Spinal Surgery, Yuyao People's Hospital, Zhejiang Province, China
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Wu J, Miao J, Chen G, Xu H, Wen W, Xu H, Liu L. Finite element biomechanical analysis of 3D printed intervertebral fusion cage in osteoporotic population. BMC Musculoskelet Disord 2024; 25:129. [PMID: 38347518 PMCID: PMC10860281 DOI: 10.1186/s12891-024-07221-7] [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: 08/10/2023] [Accepted: 01/21/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE To study the biomechanical characteristics of each tissue structure when using different 3D printing Cage in osteoporotic patients undergoing interbody fusion. METHODS A finite element model of the lumbar spine was reconstructed and validated with regarding a range of motion and intervertebral disc pressure from previous in vitro studies. Cage and pedicle screws were implanted and part of the lamina, spinous process, and facet joints were removed in the L4/5 segment of the validated mode to simulate interbody fusion. A 280 N follower load and 7.5 N·m moment were applied to different postoperative models and intact osteoporotic model to simulate lumbar motion. The biomechanical characteristics of different models were evaluated by calculating and analyzing the range of motion of the fixed and cephalic adjacent segment, the stress of the screw-rod system, the stress at the interface between cage and L5 endplate, and intervertebral disc pressure of the adjacent segment. RESULTS After rigid fixation, the range of motion of the fixed segment of model A-C decreased significantly, which was much smaller than that of the osteoporotic model. And with the increase of the axial area of the interbody fusion cages, the fixed segment of model A-C tended to be more stable. The range of motion and intradiscal pressure of the spinal models with different interbody fusion cages were higher than those of the complete osteoporosis model, but there was no significant difference between the postoperative models. On the other hand, the L5 upper endplate stress and screw-rod system stress of model A-C show a decreasing trend in different directions of motion. The stress of the endplate is the highest during flexion, which can reach 40.5 MPa (model A). The difference in endplate stress between models A-C was the largest during lateral bending. The endplate stress of models A and B was 150.5% and 140.9% of that of model C, respectively. The stress of the screw-rod system was the highest during lateral bending (model A, 102.0 MPa), which was 108.4%, 102.4%, 110.4%, 114.2% of model B and 158.5%, 110.1%, 115.8%, 125.4% of model C in flexion, extension, lateral bending, and rotation, respectively. CONCLUSIONS For people with osteoporosis, no matter what type of cage is used, good immediate stability can be achieved after surgery. Larger cage sizes provide better fixation without significantly increasing ROM and IDP in adjacent segments, which may contribute to the development of ASD. In addition, larger cage sizes can disperse endplate stress and reduce stress concentration, which is of positive significance in preventing cage subsidence after operation. The cage and screw rod system establish a stress conduction pathway on the spine, and a larger cage greatly enhances the stress-bearing capacity of the front column, which can better distribute the stress of the posterior spine structure and the stress borne by the posterior screw rod system, reduce the stress concentration phenomenon of the nail rod system, and avoid exceeding the yield strength of the material, resulting in the risk of future instrument failure.
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Affiliation(s)
- Jincheng Wu
- Department of Emergency Trauma Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China, 48 Baishuitang Road, Longhua District, 571700
| | - Jun Miao
- Tianjin Hospital, Tianjin University, Tianjin, China
| | | | - Hanpeng Xu
- Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wangqiang Wen
- The First Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China
| | - Haoxiang Xu
- The Second People's Hospital of Hefei, Hefei, Anhui, China
| | - Lizhu Liu
- Department of Emergency Trauma Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China, 48 Baishuitang Road, Longhua District, 571700.
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White MD, Uribe JS. Transpsoas Approaches to the Lumbar Spine: Lateral and Prone. Neurosurg Clin N Am 2023; 34:609-617. [PMID: 37718107 DOI: 10.1016/j.nec.2023.06.008] [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] [Indexed: 09/19/2023]
Abstract
The lateral transpsoas approach has become fundamental to minimally invasive spine surgery. The large interbody grafts that can be placed through this approach allow for robust arthrodesis of the anterior column, indirect decompression, and restoration of lordosis without disrupting the posterior musculature or ligamentous structures. The lateral decubitus position has traditionally been used for this approach but the prone position has gained popularity because it can reduce operating times for patients who also require posterior pedicle screw fixation. The transpsoas approach can be effectively performed in either position but surgeons should know the nuances that distinguish them.
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Affiliation(s)
- Michael D White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Kotheeranurak V, Jitpakdee K, Lin GX, Mahatthanatrakul A, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim JS. Subsidence of Interbody Cage Following Oblique Lateral Interbody Fusion: An Analysis and Potential Risk Factors. Global Spine J 2023; 13:1981-1991. [PMID: 34920690 PMCID: PMC10556923 DOI: 10.1177/21925682211067210] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES This study aimed to report the incidence and potential risk factors of polyetheretherketone (PEEK) cage subsidence following oblique lateral interbody fusion (OLIF) for lumbar degenerative diseases. We proposed also an algorithm to minimize subsidence following OLIF surgery. METHODS The study included a retrospective cohort of 107 consecutive patients (48 men and 59 women; mean age, 67.4 years) who had received either single- or multi-level OLIF between 2012 and 2019. Patients were classified into subsidence and non-subsidence groups. PEEK cage subsidence was defined as any violation of either endplate from the computed tomography scan in both sagittal and coronal views. Preoperative variables such as age, sex, body mass index, bone mineral density (BMD) measured by preoperative dual-energy X-ray absorptiometry, smoking status, corticosteroid use, diagnosis, operative level, multifidus muscle cross-sectional area, and multifidus muscle fatty degeneration were collected. Age-related variables (height and length) were also documented. Univariate and multivariate logistic regression analyses were used to analyze the risk factors of subsidence. RESULTS Of the 107 patients (137 levels), 50 (46.7%) met the subsidence criteria. Higher PEEK cage height had the strongest association with subsidence (OR = 9.59, P < .001). Other factors significantly associated with cage subsistence included age >60 years (OR = 3.15, P = .018), BMD <-2.5 (OR = 2.78, P = .006), and severe multifidus muscle fatty degeneration (OR = 1.97, P = .023). CONCLUSIONS Risk factors for subsidence in OLIF were age >60 years, BMD < -2.5, higher cage height, and severe multifidus muscle fatty degeneration. Patients who had subsidence had worse early (3 months) postoperative back and leg pain.
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Affiliation(s)
- Vit Kotheeranurak
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Khanathip Jitpakdee
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, PR China
| | | | - Weerasak Singhatanadgige
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Worawat Limthongkul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Jin-Sung Kim
- Spine Center, Department of Neurosurgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Wang J, Geng Z, Wu J, Liu J, Zhang Z, Miao J, Li R. Biomechanical properties of lumbar vertebral ring apophysis cage under endplate injury: a finite element analysis. BMC Musculoskelet Disord 2023; 24:695. [PMID: 37649054 PMCID: PMC10466841 DOI: 10.1186/s12891-023-06792-1] [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: 05/09/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE This study aimed to compare the biomechanical properties of lumbar interbody fusion involving two types of cages. The study evaluated the effectiveness of the cage spanning the ring apophysis, regardless of the endplate's integrity. METHODS A finite element model of the normal spine was established and validated in this study. The validated model was then utilized to simulate Lateral Lumbar Interbody Fusion (LLIF) with posterior pedicle screw fixation without posterior osteotomy. Two models of interbody fusion cage were placed at the L4/5 level, and the destruction of the bony endplate caused by curetting the cartilaginous endplate during surgery was simulated. Four models were established, including Model 1 with an intact endplate and long cage spanning the ring apophysis, Model 2 with endplate decortication and long cage spanning the ring apophysis, Model 3 with an intact endplate and short cage, and Model 4 with endplate decortication and short cage. Analyzed were the ROM of the fixed and adjacent segments, screw rod system stress, interface stress between cage and L5 endplate, trabecular bone stress on the upper surface of L5, and intervertebral disc pressure (IDP) of adjacent segments. RESULTS There were no significant differences in ROM and IDP between adjacent segments in each postoperative model. In the short cage model, the range of motion (ROM), contact pressure between the cage and endplate, stress in L5 cancellous bone, and stress in the screw-rod system all exhibited an increase ranging from 0.4% to 79.9%, 252.9% to 526.9%, 27.3% to 133.3%, and 11.4% to 107%, respectively. This trend was further amplified when the endplate was damaged, resulting in a maximum increase of 88.6%, 676.1%, 516.6%, and 109.3%, respectively. Regardless of the integrity of the endplate, the long cage provided greater support strength compared to the short cage. CONCLUSIONS Caution should be exercised during endplate preparation and cage placement to maintain the endplate's integrity. Based on preoperative X-ray evaluation, the selection of a cage that exceeds the width of the pedicle by at least 5 mm (ensuring complete coverage of the vertebral ring) has demonstrated remarkable biomechanical performance in lateral lumbar interbody fusion procedures. By opting for such a cage, we expect a reduced occurrence of complications, including cage subsidence, internal fixation system failure, and rod fracture.
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Affiliation(s)
- Jian Wang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Ziming Geng
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jincheng Wu
- The Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan, China
| | - Jianchao Liu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Zepei Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jun Miao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China.
| | - Ruihua Li
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China.
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Mok JM, Lin Y, Tafur JC, Diaz RL, Amirouche F. Biomechanical Comparison of Multilevel Stand-Alone Lumbar Lateral Interbody Fusion With Posterior Pedicle Screws: An In Vitro Study. Neurospine 2023; 20:478-486. [PMID: 37401066 PMCID: PMC10323329 DOI: 10.14245/ns.2244734.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/06/2023] [Accepted: 02/05/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Lumbar lateral interbody fusion (LLIF) allows placement of large interbody cages while preserving ligamentous structures important for stability. Multiple clinical and biomechanical studies have demonstrated the feasibility of stand-alone LLIF in single-level fusion. We sought to compare the stability of 4-level stand-alone LLIF utilizing wide (26 mm) cages with bilateral pedicle screw and rod fixation. METHODS Eight human cadaveric specimens of L1-5 were included. Specimens were attached to a universal testing machine (MTS 30/G). Flexion, extension, and lateral bending were attained by applying a 200 N load at a rate of 2 mm/sec. Axial rotation of ± 8° of the specimen was performed at 2°/sec. Three-dimensional specimen motion was recorded using an optical motion-tracking device. Specimens were tested in 4 conditions: (1) intact, (2) bilateral pedicle screws and rods, (3) 26-mm stand-alone LLIF, (4) 26-mm LLIF with bilateral pedicle screws and rods. RESULTS Compared to the stand-alone LLIF, bilateral pedicle screws and rods had 47% less range of motion in flexion-extension (p < 0.001), 21% less in lateral bending (p < 0.05), and 20% less in axial rotation (p = 0.1). The addition of bilateral posterior instrumentation to the stand-alone LLIF resulted in decreases of all 3 planes of motion: 61% in flexion-extension ( p < 0.001), 57% in lateral bending (p < 0.001), 22% in axial rotation (p = 0.002). CONCLUSION Despite the biomechanical advantages associated with the lateral approach and 26 mm wide cages, stand-alone LLIF for 4-level fusion is not equivalent to pedicle screws and rods.
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Affiliation(s)
- James M. Mok
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Ye Lin
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | - Farid Amirouche
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
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Godolias P, Tataryn ZL, Plümer J, Cibura C, Freyvert Y, Heep H, Dudda M, Schildhauer TA, Chapman JR, Oskouian RJ. Cage subsidence-A multifactorial matter! ORTHOPADIE (HEIDELBERG, GERMANY) 2023:10.1007/s00132-023-04363-9. [PMID: 37012487 DOI: 10.1007/s00132-023-04363-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 04/05/2023]
Abstract
STUDY DESIGN Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates. METHODS This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, t‑scores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch. RESULTS Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (p = 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (p = 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal t‑scores (p = 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (p = 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (p < 0.01). CONCLUSION Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low t‑scores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.
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Affiliation(s)
- Periklis Godolias
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital Essen-Werden, Propsteistraße 2, 45239, Essen, Germany.
| | - Zachary L Tataryn
- Seattle Science Foundation, 550 17th Avenue, Suite 600, WA 98122, Seattle, USA
| | - Jonathan Plümer
- Seattle Science Foundation, 550 17th Avenue, Suite 600, WA 98122, Seattle, USA
| | - Charlotte Cibura
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Yevgeniy Freyvert
- Seattle Science Foundation, 550 17th Avenue, Suite 600, WA 98122, Seattle, USA
| | - Hansjörg Heep
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital Essen-Werden, Propsteistraße 2, 45239, Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Department of Orthopedics and Trauma Surgery, BG-Klinikum Duisburg, Großenbaumer-Allee 250, 47249, Duisburg, Germany
| | - Thomas A Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jens R Chapman
- Seattle Science Foundation, 550 17th Avenue, Suite 600, WA 98122, Seattle, USA
| | - Rod J Oskouian
- Seattle Science Foundation, 550 17th Avenue, Suite 600, WA 98122, Seattle, USA
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Salmons HI, Baird MD, Dearden ME, Wagner SC, Sebastian AS. Prone Versus Lateral Decubitus Positioning for Direct Lateral Interbody Fusion. Clin Spine Surg 2022; 35:351-353. [PMID: 34966037 DOI: 10.1097/bsd.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/01/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | - Michael D Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Marissa E Dearden
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott C Wagner
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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11
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McGrath LB, Gadjradj PS, Hussain I, Takoushian E, Kirnaz S, Goldberg JL, Sommer F, Navarro-Ramirez R, Mykolajtchuk C, Ng AZ, Basilious M, Medary B, Härtl R. Ten-Step 3-Dimensional-Navigated Single-Stage Lateral Surgery With Microtubular Decompression: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:406-412. [PMID: 36227239 DOI: 10.1227/ons.0000000000000366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/14/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Single-stage lateral lumbar interbody fusion is a safe and effective procedure that relies on indirect decompression and fusion to treat various lumbar pathologies. This technique, however, has an overall 9% rate of indirect decompression failure, which may require additional surgery to achieve adequate direct decompression. To address this concern, we modified this technique by adding a minimally invasive, direct tubular decompression in lateral position when indicated. No study has described the technical nuances of incorporating a microtubular decompression into the single-stage lateral lumbar interbody fusion workflow (SSLLIF+). OBJECTIVE To report on the procedural steps and clinical outcomes of the SSLLIF+. METHODS In this retrospective case series of prospectively collected data, we present the detailed surgical approach of the SSLLIF+ with a single-center case series over a 5-year period. Surgical and clinical outcomes are presented. RESULTS A total of 7 patients underwent a SSLLIF+ with a total of 18 levels fused and 7 levels decompressed. The SSLLIF+ was successfully performed in all cases without the occurrence of intraoperative complications in this case series. There was 1 revision after 20 months of follow-up because of adjacent segment disease. There was no need for further direct decompression in a delayed fashion. CONCLUSION SSLLIF with direct microtubular decompression in lateral position is a safe and effective procedure in patients where indirect decompression alone may not achieve the surgical goal. Adherence to minimally invasive spine surgery principles and thoughtful patient selection facilitate the successful management of these patients while demonstrating short hospital stay and low-risk of perioperative complications.
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Affiliation(s)
- Lynn B McGrath
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
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12
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Lambrechts MJ, Siegel N, Heard JC, Karamian BA, Dambly J, Baker S, Brush P, Fras S, Canseco JA, Kaye ID, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Trends in Single-Level Lumbar Fusions Over the Past Decade Using a National Database. World Neurosurg 2022; 167:e61-e69. [PMID: 35963610 DOI: 10.1016/j.wneu.2022.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To compare rates of different fusion techniques using a nationwide database over the last decade and identify differences in complications and readmissions based on fusion technique. METHODS All elective, single-level lumbar fusions performed by orthopaedic surgeons from 2011 to 2020 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Rates of lumbar fusion technique posterolateral decompression and fusion [PLDF], combined transforaminal lumbar interbody fusion and PLDF, anterior lumbar or lateral lumbar interbody fusion [ALIF/LLIF], and combined ALIF/LLIF and PLDF were recorded, and 30-day complications and readmissions were compared. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS Inclusion criteria were met by 28,413 fusions: 8749 (30.8%) PLDFs, 11,973 (42.1%) transforaminal lumbar interbody fusions, 4769 (16.8%) ALIF/LLIFs, and 2922 (10.3%) combined ALIF/LLIF and PLDFs. The number of fusions increased over time with 1227 fusions performed in 2011 and 3958 fusions performed in 2019. Interbody fusions also increased over time with a subsequent decrease in PLDFs (39.0% in 2011, 25.2% in 2020). Patients were more likely to be discharged home over the course of the decade (85.4% in 2011, 95.0% in 2020). No difference was observed between the techniques regarding complications or readmissions. The modified 5-item frailty index was predictive of complications (odds ratio, 2.05; P = 0.001) and readmissions (odds ratio, 2.61; P < 0.001). CONCLUSIONS Lumbar fusions have continued to increase over the last decade with an increasing proportion of interbody fusions. Complications and readmissions appear to be driven by patient comorbidity and not fusion technique.
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Affiliation(s)
- Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julia Dambly
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sydney Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parker Brush
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sebastian Fras
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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13
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Shinmura K, Demura S, Kato S, Yokogawa N, Handa M, Annen R, Kobayashi M, Yamada Y, Nagatani S, Murakami H, Tsuchiya H. A Modified Spinal Reconstruction Method Reduces Instrumentation Failure in Total En Bloc Spondylectomy for Spinal Tumors. Spine Surg Relat Res 2022; 7:60-65. [PMID: 36819620 PMCID: PMC9931410 DOI: 10.22603/ssrr.2022-0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/24/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Long-term spinal stability after total en bloc spondylectomy (TES) is challenging. The aim of this study was to examine whether the new method could reduce the incidence of instrumentation failure (IF). Methods We retrospectively compared 116 patients with spinal tumors who underwent TES between 2010 and 2019 and were followed up for >1 year. IF, cage subsidence, and complications were evaluated. Propensity score matching between conventional and new method groups was performed for age, sex, body mass index, preoperative radiotherapy, number of resected vertebrae, number of instrumented vertebrae, tumor level, and follow-up period. There were 25 cases each in the conventional and new method groups. The conventional method used a titanium mesh cage for anterior reconstruction and 5.5-mm-diameter titanium alloy rods for posterior fixation. The new method used a more robust cage for anterior reconstruction, bone grafting was performed around the cage, and 6.0-mm-diameter cobalt chromium rods were used for posterior fixation. We compared the incidence of IF and cage subsidence after TES between the conventional and new method groups. Results While 5 out of 25 patients (20.0%) in the conventional method group experienced IF, none from the new method group experienced IF. Three-year implant survival rates were 87.3% in the conventional and 100% in the new method groups. The new method group had a significantly higher implant survival rate (p<0.01). Cage subsidence was observed in 11 of 25 (44/0%) patients in the conventional method and 1 of 25 (4.0%; significantly lower, p<0.05) in the new method group. Conclusions The new reconstruction method significantly reduced IF incidence in patients with TES.
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Affiliation(s)
- Kazuya Shinmura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Satoru Demura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Satoshi Kato
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Noriaki Yokogawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Makoto Handa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Ryohei Annen
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Motoya Kobayashi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yohei Yamada
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Satoshi Nagatani
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Muacevic A, Adler JR. Excessive Fluid in the Lumbar Facet Joint as a Predictor of Radiological Outcomes After Lateral Lumbar Interbody Fusion. Cureus 2022; 14:e30217. [PMID: 36381790 PMCID: PMC9650774 DOI: 10.7759/cureus.30217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/12/2022] [Indexed: 01/24/2023] Open
Abstract
Background Preoperative segmental instability maybe a predictor of postoperative outcomes when treated with lateral lumbar interbody fusion (LLIF). An abnormal collection of fluid within the facet joint has been described as a sign of segmental instability. The potential relationship between this radiological sign and its prognostic relevance for indirect decompression (ID) has not been investigated. Methods Clinical and radiologic results from patients undergoing LLIF in a single institution between 2007 and 2014 were evaluated retrospectively. Patients were divided into two groups: those presenting with excessive fluid (EF) in the facet joints on T2-MRI and those with a normal amount of facet fluid with less than 1mm, which were controls. Radiological parameters were foraminal height, disc height, Cobb angle, and lumbar lordosis. Results A total of 21 patients (43 operated levels) were evaluated pre- and postoperatively. Mean disc height, mean foraminal height, and coronal Cobb angles were statistically significantly improved after LLIF. Only the EF group showed significant improvement in radiological markers after ID; the mean disc height improved from 5.5±2 to 8.8±1mm (p=0.001), mean foraminal height improved from 16.88±3 to 20.53±3mm (p=0.002), and the mean Cobb angle improved from 27.7±16 to 14±13 (p=0.018). Conclusions Patients undergoing LLIF with the radiological findings of EF in the facet joints demonstrated significant improvement in radiological outcomes of ID. Further studies should validate these findings in larger data sets.
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15
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Finite element analysis of the effect of anterior dynamic plating on two-level anterior cervical discectomy fusion biomechanics. World Neurosurg 2022; 163:e43-e52. [PMID: 35176523 DOI: 10.1016/j.wneu.2022.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Limitations of anterior cervical discectomy and fusion (ACDF) relate to mechanical failure of the construct after recurring subsidence and migration. This study aims to evaluate the effect of the maximum rotation of variable angle screws on the range of motion (ROM), cage migration, and subsidence. METHODS Five finite element (FE) models were developed from a C2-C7 cervical spine model. The first model was an intact C2-C7 spine model, and the second model was an altered C2-C7 model with C4-C6 cage insertion and a 2-level static plate. The other three models were altered C2-C7 models with the same C4-C6 cage insertion and a 2-level dynamic plate. RESULTS ROM of C4-C6 in the static plate model was reduced by about 14º from the intact model, while only reduced by about 9o in dynamic plate models. The maximum migration and subsidence at the cage-endplate interface in the dynamic plate models were lower than that in the static plate model under all moments. The von-Mises stress of the C3-C4 and C6-C7 discs in the dynamic plate models was lower than that in the static plate model. CONCLUSION Results indicate dynamic plating has promising potential (higher ROM and lower von Mises stress of discs) for stabilization in multilevel ACDF than static plate, though both dynamic plate and static plate has lower ROM than the intact model. Lower screw rotational angle has superior biomechanical performance (lower migration and subsidence) to higher rotational angle in multilevel applications regardless of loading.
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16
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Guha D, Mushlin HM, Muthiah N, Vodovotz LL, Agarwal N, Alan N, Hamilton DK, Okonkwo DO, Kanter AS. CT Hounsfield Units as a predictor of reoperation and graft subsidence following standalone and multi-level lateral lumbar interbody fusion. World Neurosurg 2022; 161:e417-e426. [PMID: 35149250 DOI: 10.1016/j.wneu.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Standalone single and multi-level lateral lumbar interbody fusion (LLIF) are increasingly being applied to treat degenerative spinal conditions in a less invasive fashion. Graft subsidence following LLIF is a known complication and has been associated with poor bone mineral density (BMD). Previous research has demonstrated the utility of CT Hounsfield Units (HU) as a surrogate for BMD. This study aims to investigate the relationship between CT HU and subsidence and reoperation after standalone and multi-level LLIF. METHODS A prospectively-maintained single-institution database was retrospectively reviewed for LLIF patients from 2017-2020 including single and multi-level standalone cases with or without supplemental posterior fixation. Data on demographics, graft parameters, BMD on DEXA, preoperative mean segmental CT HU, and postoperative subsidence and reoperation, were collected. Three-foot standing radiographs were used to measure preoperative global sagittal alignment and disc height, and subsidence at last follow-up. Subsidence was classified using the Marchi grading system corresponding to disc height loss: Grade 0: 0-24%; I: 25-49%; II: 50-74%; III: 75-100%. RESULTS Eighty-nine LLIF patients met study criteria, with mean follow-up 19.9 ± 13.9 months. Among the 54 patients who underwent single-level LLIF, mean segmental HU was 152.0 ± 8.7 in 39 patients with Grade 0 subsidence, 136.7 ± 10.4 in nine with Grade I subsidence, 133.9 ± 23.1 in three with Grade II subsidence, and 119.9 ± 30.9 in three with Grade III subsidence (p=0.032). In the 96 instrumented levels in 35 patients who underwent multi-level LLIF, 85 had Grade 0 subsidence, 9 Grade I, 1 Grade II, and 1 Grade III, with no differences in HU. In multivariate logistic regression, increased CT HU was independently associated with a decreased risk of reoperation in both single-level and multi-level LLIF (OR:0.98, 95%CI:0.97-0.99, p=0.044; and OR:0.97, 95%CI: 0.94-0.99, p=0.017, respectively). Overall BMD on DEXA was not associated with graft subsidence nor reoperation. Using a receiver-operating-characteristic curve to establish separation between patients requiring reoperation and those that did not, the determined threshold HU for single-level LLIF was 131.4 (sensitivity 0.62, specificity 0.65), and for multi-level was 131.0 (sensitivity 0.67, specificity 0.63). CONCLUSIONS Lower CT HU are independently associated with an increased risk of graft subsidence following single-level LLIF. In addition, lower CT HU significantly increased the risk of reoperation in both single and multi-level LLIF with a critical threshold of 131 HU. Preoperative CT HU may provide a more robust gauge of local bone quality and the likelihood of graft subsidence requiring reoperation following LLIF, than overall BMD.
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Affiliation(s)
- Daipayan Guha
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Harry M Mushlin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nallammai Muthiah
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lena L Vodovotz
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Poor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated with Intraoperative Endplate Injuries and Late-onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review. Clin Orthop Relat Res 2022; 480:163-188. [PMID: 34324459 PMCID: PMC8673985 DOI: 10.1097/corr.0000000000001915] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/06/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND A major complication of lateral lumbar interbody fusion (LLIF) is cage subsidence, which may lead to clinical problems, including loss of disc height correction, altered spinal alignment, recurrent pain, and vertebral body fracture. A thorough review of the current knowledge about the risk factors for the two types of cage subsidence after LLIF-intraoperative endplate injury and late-onset cage subsidence-could bring attention to well-established risk factors for clinical consideration while identifying any incompletely characterized factors that require further research to clarify. QUESTIONS/PURPOSES We performed a systematic review to answer the following questions: (1) Are bone quality and surrogates for bone quality, such as patient age and sex, associated with an increased likelihood of cage subsidence? (2) Are implant-related factors associated with an increased likelihood of cage subsidence? METHODS Two independent reviewers comprehensively searched Medline, Embase, Cochrane Library, PubMed, and Web of Science from 1997 to 2020 to identify all potential risk factors for cage subsidence after LLIF. Discrepancies were settled through discussion during full-text screening. Search terms included "lateral" AND "interbody fusion" AND "subsidence" OR "settling" OR "endplate injury" OR "endplate violation" WITHOUT "cervical" OR "transforaminal" OR "biomechanical." Eligible studies were retrospective or prospective comparative studies, randomized controlled trials, and case series with sample sizes of 10 patients or more reporting risk factors for cage subsidence or endplate injury after LLIF. Studies that involved cervical interbody fusions and biomechanical and cadaveric experiments were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the studies' quality of evidence. The initial database review found 400 articles. Thirty-four articles with moderate- to very-low-quality evidence met the inclusion criteria for analysis. A total of 3233 patients (58% [1860] of whom were female) were included in this review. Two types of cage subsidence were reviewed: late-onset cage subsidence, which occurs gradually postoperatively, and intraoperative endplate injury, which is derived from iatrogenic endplate violation during endplate preparation or cage insertion. Among 20 studies with moderate quality of evidence according to the GRADE criteria, eight studies reported risk factors for cage subsidence related to bone mineral density and its surrogates and 12 studies focused on risk factors regarding implant factors, including cage dimension, cage material, construct length, and supplementary instrumentation. RESULTS Patients with a dual x-ray absorptiometry T-score of -1.0 or less, age older than 65 years, and female sex were considered to have a high risk of both types of cage subsidence. Regarding cage size, cage width ≥ 22 mm helped to avoid late-onset cage subsidence, and cage height ≤ 11 mm was recommended by some studies to avoid intraoperative endplate injuries. Studies recommended that multilevel LLIF should be conducted with extra caution because of a high risk of losing the effect of indirect decompression. Studies found that standalone LLIF might be sufficient for patients without osteoporosis or obesity, and supplementary instrumentation should be considered to maintain the postoperative disc height and prevent subsidence progression in patients with multiple risk factors. The effect of the bone graft, cage material, endplate condition, and supplementary instrumentation on cage subsidence remained vague or controversial. CONCLUSION Patients with poor bone density, patients who are older than 65 years, and female patients should be counseled about their high risk of developing cage subsidence. Surgeons should avoid narrow cages when performing LLIF to minimize the risk of late-onset cage subsidence, while being cautious of an aggressive attempt to restore disc height with a tall cage as it may lead to intraoperative endplate injury. For multilevel constructs, direct decompression approaches, such as posterior and transforaminal LIF, should be considered before LLIF, since the effect of indirect decompression may be difficult to maintain in multilevel LLIF because of high risks of cage subsidence. The effect of the cage material and supplementary instrumentation require stronger evidence from prospectively designed studies with larger sample size that randomly assign patients to polyetheretherketone (PEEK) or titanium cages and different fixation types. Future research on intraoperative endplate injuries should focus on the specific timing of when endplate violation occurs with the help of intraoperative imaging so that attempts can be made to minimize its occurrence. LEVEL OF EVIDENCE Level IV, therapeutic study.
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18
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Risk factors for intraoperative endplate injury during minimally-invasive lateral lumbar interbody fusion. Sci Rep 2021; 11:20149. [PMID: 34635757 PMCID: PMC8505407 DOI: 10.1038/s41598-021-99751-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/30/2021] [Indexed: 01/13/2023] Open
Abstract
During lateral lumbar interbody fusion (LLIF), unintended intraoperative endplate injury (IEPI) can occur and thereafter lead cage subsidence. The aim of this study was to investigate the incidence of IEPI during LLIF, and its predisposing factors. A retrospective review was conducted on consecutive patients (n = 186; mean age, 70.0 ± 7.6 years) who underwent LLIF at 372 levels. Patient’s demographic and surgical data were compared between patients with and without IEPI. Also, the radiographic data of each level were compared between intact and IEPI segments. IEPI was identified at 76 levels (20.4%) in 65 patients. The incidences of IEPI at every 100 consecutive segments were not different. When 372 segments were analyzed independently, sagittal disc angle (DA) in the extended position (4.3° ± 3.6° at IEPI segments vs. 6.4° ± 4.0° at intact segments), the difference between sagittal DA in the extended position and cage angle (− 2.2° ± 4.0° vs. 0.0° ± 3.9°), and the difference between preoperative disc height and cage height (− 5.4 mm ± 2.4 mm vs. − 4.7 mm ± 2.0 mm) were different significantly. Also, endplate sclerosis was more common at intact segments than IEPI segments (33.2% vs. 17.3%). Multivariate analysis showed that male sex (odds ratio [OR] 0.160; 95% confidence interval [CI] 0.036–0.704), endplate sclerosis (OR 3.307; 95% CI 1.450–8.480), and sagittal DA in the extended position (OR 0.674; 95% CI 0.541–0.840) were significant associated factors for IEPI. IEPI was correlated not with surgeon’s experience, but with patient factors, such as sex, preoperative disc angle, and endplate sclerosis. Careful surgical procedures should be employed for patients with these predisposing factors.
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The Effect of Patient Position on Psoas Morphology and in Lumbar Lordosis. World Neurosurg 2021; 153:e131-e140. [PMID: 34166827 DOI: 10.1016/j.wneu.2021.06.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Among the interbody fusions, lateral lumbar interbody fusion allows access to the lumbar spine through the major psoas muscle, which offers several advantages to the spine surgeon. However, some of its drawbacks cause surgeons to avoid using it as a daily practice. Therefore, to address some of these challenges, we propose the prone transpsoas technique, differing mainly from the traditional technique on patient position-moving from lateral to prone decubitus, theoretically enhancing the lordosis and impacting the psoas morphology. METHODS Twenty-four consecutive patients were invited to have magnetic resonance imaging examinations in 3 different positions (prone, dorsal, lateral). Two observers measured the following parameters: vertebral body size, psoas diameter, psoas anterior border distance, plexus distance, total lumbar lordosis, distal lumbar lordosis, and proximal lumbar lordosis. Values of P < 0.05 were deemed significant. RESULTS The prone position yielded a significant increase in the lumbar lordosis, both in L1-S1 (57° vs. 46.5°) and proximal lordosis (40.4° vs. 36.9°) compared with the lateral position. Regarding the morphologic aspects, patients in the prone position presented lesser psoas muscles forward shift, but no difference was noted in the plexus position neither for L3-L4 nor L4-L5. CONCLUSIONS The prone position resulted in a significantly increased lumbar lordosis, both distal and proximal, which may enable the spine surgeon to achieve significant sagittal restoration just by positioning. The prone position also produced a posterior retraction of the psoas muscle. However, it did not significantly affect the position of the plexus concerning the vertebral body.
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Hai Y, Liu J, Liu Y, Liu T, Zhang X, Pan A, Zhang Y, Ding H, Wu Y, Han B, Tang X. Expert Consensus on Clinical Application of Lateral Lumbar Interbody Fusion: Results From a Modified Delphi Study. Global Spine J 2021; 13:995-1004. [PMID: 34000874 DOI: 10.1177/21925682211012688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Modified Delphi study. OBJECTIVE The objective of this study was to establish expert consensus on the application of lateral lumbar interbody fusion (LLIF) by using the modified Delphi study. METHODS From June 2019 to March 2020, Members of the Chinese Study Group for Lateral Lumbar Spine Surgery were selected to collect expert feedback using the modified Delphi method where 65 spine surgeons from all over China agreed to participate. Four rounds were performed: 1 face-to-face meeting and 3 subsequent survey rounds. The consensus was achieved with ≥a 70.0% agreement for each question. The recommendation of grade A was defined as ≥90.0% of the agreement for each question. The recommendation of grade B was defined as 80.0-89.9% of the agreement for each question. The recommendation of grade C was defined as 70.0-79.9% of the agreement for each question. RESULTS A total of 65 experts formed a panelist group, and the number of questionnaires collected was 63, 59, and 62 in the 3 rounds. In total, 5 sections, 71 questions, and 382 items achieved consensus after the Delphi rounds including summary; preoperative evaluation; application at the lumbar spinal stenosis, lumbar disc herniation, lumbar spondylolisthesis, adult degenerative scoliosis, postoperative adjacent segmental degeneration, and revision surgery; complications; and postoperative follow-up evaluation of LLIF. CONCLUSION The modified Delphi method was utilized to ascertain an expert consensus from the Chinese Study Group for Lateral Lumbar Spine Surgery to inform clinical decision-making in the application of LLIF. The salient grade A recommendations of the survey are enumerated.
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Affiliation(s)
- Yong Hai
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jingwei Liu
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuzeng Liu
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tie Liu
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinuo Zhang
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Aixing Pan
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yiqi Zhang
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hongtao Ding
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuxuan Wu
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Bo Han
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinli Tang
- Department of Orthopedic Surgery, 74639Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Lai O, Chen Y, Chen Q, Hu Y, Ma W. Cadaveric biomechanical analysis of multilevel lateral lumbar interbody fusion with and without supplemental instrumentation. BMC Musculoskelet Disord 2021; 22:280. [PMID: 33722233 PMCID: PMC7962251 DOI: 10.1186/s12891-021-04151-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/08/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND This study was to evaluate and compare the biomechanical features of multilevel lateral lumbar interbody fusion (LLIF) with or without supplemental instrumentations. METHODS Six human lumbar specimens were tested under multidirectional nondestructive moments (7.5 N·m), with a 6 degree-of-freedom spine simulator. The overall and intervertebral range of motion (ROM) were measured optoelectronically. Each specimen was tested under the following conditions at L2-5 levels: intact; stand-alone; cage supplemented with lateral plate (LP); cage supplemented with unilateral or bilateral pedicle screw/rod (UPS or BPS). RESULTS Compared with intact condition, the overall and intersegmental ROM were significantly reduced after multilevel stand-alone LLIF. The ROM was further reduced after using LP instrumentation. In flexion-extension (FE) and axial rotation (AR), pedicle screw/rod demonstrated greater overall ROM reduction compared to LP (P < 0.01), and bilateral greater than unilateral (P < 0.01). In lateral bending (LB), BPS demonstrated greater overall ROM reduction compared to UPS and LP (P < 0.01), however, UPS and LP showed similar reduction (P = 0.245). Intervertebral ROM reductions showed similar trend as the overall ones after using different types of instrumentation. However, at L2/3 (P = 0.57) and L3/4 (P = 0.097) levels, the intervertebral ROM reductions in AR were similar between UPS and LP. CONCLUSIONS The overall and intervertebral stability increased significantly after multilevel LLIF with or without supplemental instrumentation. BPS provided the greatest stability, followed by UPS and LP. However, in clinical practice, less invasive adjunctive fixation methods including UPS and LP may provide sufficient biomechanical stability for multilevel LLIF.
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Affiliation(s)
- Oujie Lai
- Department of Spine Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, 315040, People's Republic of China
| | - Yunlin Chen
- Department of Spine Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, 315040, People's Republic of China
| | - Qixin Chen
- Department of Spine Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China.
| | - Yong Hu
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, 315040, People's Republic of China
| | - Weihu Ma
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, 315040, People's Republic of China
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Screven R, Pressman E, Rao G, Freeman TB, Alikhani P. The Safety and Efficacy of Stand-Alone Lateral Lumbar Interbody Fusion for Adjacent Segment Disease in a Cohort of 44 Patients. World Neurosurg 2021; 149:e225-e230. [PMID: 33610868 DOI: 10.1016/j.wneu.2021.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND A mainstay of treatment for symptomatic adjacent segment disease (ASD) has consisted of revision with posterior decompression and fusion. This carries significant morbidity and can be technically difficult. An alternative is stand-alone lateral lumbar interbody fusion (LLIF), which may avoid complications associated with revision surgery. We describe the largest cohort of patients treated with LLIF for ASD to our knowledge. METHODS We conducted a retrospective cohort study on all patients who underwent transpsoas LLIF for ASD at a single academic center between 2012 and 2019. Postoperative improvement was measured using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). RESULTS Forty-four patients who underwent LLIF for ASD were identified. Median age was 65 years. Median time from index surgery to ASD development was 78 months. Median levels fused via LLIF was 1. Our median follow-up was 358 days. At follow-up, the median VAS back pain score was 0 (mean, 0.884), median VAS leg pain score was 1 (mean, 0.953), and median ODI was 8. The median improvement for VAS back pain was 8, for VAS leg pain was 6, and for ODI was 40. No patients suffered new neurologic symptoms postoperatively. Of the 17 patients who initially presented with non-pain neurologic symptoms, 8 (47.1%) experienced complete resolution of symptoms, and 5 (29.4%) experienced only some improvement. CONCLUSIONS To our knowledge, this is the largest cohort study of patients to date evaluating stand-alone LLIF for ASD. Our patient outcomes show it is safe and effective with low risk of morbidity.
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Affiliation(s)
- Ryan Screven
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Gautam Rao
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Thomas B Freeman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
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Pimenta L, Pokorny G, Amaral R, Ditty B, Batista M, Moriguchi R, Filho FM, Taylor WR. Single-Position Prone Transpsoas Lateral Interbody Fusion Including L4L5: Early Postoperative Outcomes. World Neurosurg 2021; 149:e664-e668. [PMID: 33548532 DOI: 10.1016/j.wneu.2021.01.118] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The lateral lumbar interbody fusion (LLIF) was a revolutionary approach devised by Luiz Pimenta that allowed the surgeon to access the lumbar spine through the major psoas muscle. Although the traditional LLIF had enabled enormous advances, the technique has its drawbacks. A new concept to perform the traditional LLIF has been proposed, with the patient being prone to decubitus with slightly extended legs. Our study aims to analyze the early outcomes of patients who had undergone the prone transpsoas (PTP) for degenerative spine pathologies including the L4/5 level. METHODS This study was multicentric, retrospective, nonrandomized, noncomparative, and observational. Only participants who received PTP in L4/5, with no more than 3 levels of intersomatics and fixation no further than S1, were included. The primary outcomes were the onset of new neurologic deficits and postoperative complications. Also, surgery details, such as blood loss and surgery duration, were measured. Neurologic deficits were accessed at the postoperative visit, which ranged from 7 to 14 days after surgery. RESULTS Twenty-seven patients fulfilled the inclusion and exclusion criteria, with the majority receiving PTP only in L4/5 (66.6%). The mean surgery time was 182, with 29 minutes of mean transpsoas time. Of the patients, only 1 presented the onset of a motor deficit, while 3 patients presented a new sensory deficit. Five complications occurred, none intraoperative and 5 postoperative, with only 1 directly correlated with the access. CONCLUSIONS The prone transpsoas is safe and feasible for approaching the L4/5 disk, presenting with a low rate of complication and new-onset neurologic deficits.
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Affiliation(s)
- Luiz Pimenta
- Institute of Spinal Pathology, São Paulo, Brazil; Department of Neurosurgery, University of California, San Diego, California, USA
| | | | | | - Benjamin Ditty
- Department of Neurosurgery, University of Alabama, Birmingham, Alabama, USA
| | | | | | | | - William R Taylor
- Department of Neurosurgery, University of California, San Diego, California, USA
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Campbell PG, Cavanaugh DA, Nunley P, Utter PA, Kerr E, Wadhwa R, Stone M. PEEK versus titanium cages in lateral lumbar interbody fusion: a comparative analysis of subsidence. Neurosurg Focus 2020; 49:E10. [DOI: 10.3171/2020.6.focus20367] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors have provided a review of radiographic subsidence after lateral lumbar interbody fusion (LLIF) as a comparative analysis between titanium and polyetheretherketone (PEEK) cages. Many authors describe a reluctance to use titanium cages in spinal fusion secondary to subsidence concerns due to the increased modulus of elasticity of metal cages. The authors intend for this report to provide observational data regarding the juxtaposition of these two materials in the LLIF domain.METHODSA retrospective review of a prospectively maintained database identified 113 consecutive patients undergoing lateral fusion for degenerative indications from January to December 2017. The surgeons performing the cage implantations were two orthopedic spine surgeons and two neurosurgeons. Plain standing radiographs were obtained at 1–2 weeks, 8–12 weeks, and 12 months postoperatively. Using a validated grading system, interbody subsidence into the endplates was graded at these time points on a scale of 0 to III. The primary outcome measure was subsidence between the two groups. Secondary outcomes were analyzed as well.RESULTSOf the 113 patients in the sample, groups receiving PEEK and titanium implants were closely matched at 57 and 56 patients, respectively. Cumulatively, 156 cages were inserted and recombinant human bone morphogenetic protein–2 (rhBMP-2) was used in 38.1%. The average patient age was 60.4 years and average follow-up was 75.1 weeks. Subsidence in the titanium group in this study was less common than in the PEEK cage group. At early follow-up, groups had similar subsidence outcomes. Statistical significance was reached at the 8- to 12-week and 52-week follow-ups, demonstrating more subsidence in the PEEK cage group than the titanium cage group. rhBMP-2 usage was also highly correlated with higher subsidence rates at all 3 follow-up time points. Age was correlated with higher subsidence rates in univariate and multivariate analysis.CONCLUSIONSTitanium cages were associated with lower subsidence rates than PEEK cages in this investigation. Usage of rhBMP-2 was also robustly associated with higher endplate subsidence. Each additional year of age correlated with an increased subsidence risk. Subsidence in LLIF is likely a response to a myriad of factors that include but are certainly not limited to cage material. Hence, the avoidance of titanium interbody implants secondary solely to concerns over a modulus of elasticity likely overlooks other variables of equal or greater importance.
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Agarwal N, White MD, Zhang X, Alan N, Ozpinar A, Salvetti DJ, Tempel ZJ, Okonkwo DO, Kanter AS, Hamilton DK. Impact of endplate-implant area mismatch on rates and grades of subsidence following stand-alone lateral lumbar interbody fusion: an analysis of 623 levels. J Neurosurg Spine 2020; 33:12-16. [PMID: 32114533 DOI: 10.3171/2020.1.spine19776] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stand-alone lateral lumbar interbody fusion (LLIF) is a useful minimally invasive approach for select spinal disorders, but implant subsidence may occur in up to 30% of patients. Previous studies have suggested that wider implants reduce the subsidence rate. This study aimed to evaluate whether a mismatch of the endplate and implant area can predict the rate and grade of implant subsidence. METHODS The authors conducted a retrospective review of prospectively collected data on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 surgical levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria. Thirty patients had radiographic evidence of implant subsidence. The endplates above and below the implant were measured. RESULTS A total of 30 patients with implant subsidence were identified. Of these patients, 6 had Marchi grade 0, 4 had grade I, 12 had grade II, and 8 had grade III implant subsidence. There was no statistically significant correlation between the endplate-implant area mismatch and subsidence grade or incidence. There was also no correlation between endplate-implant width and length mismatch and subsidence grade or incidence. However, there was a strong correlation between the usage of the 18-mm-wide implants and the development of higher-grade subsidence (p = 0.002) necessitating surgery. There was no significant association between the degree of mismatch or Marchi subsidence grade and the presence of postoperative radiculopathy. Of the 8 patients with 18-mm implants demonstrating radiographic subsidence, 5 (62.5%) required reoperation. Of the 22 patients with 22-mm implants demonstrating radiographic subsidence, 13 (59.1%) required reoperation. CONCLUSIONS There was no correlation between endplate-implant area, width, or length mismatch and Marchi subsidence grade for stand-alone LLIF. There was also no correlation between either endplate-implant mismatch or Marchi subsidence grade and postoperative radiculopathy. The data do suggest that the use of 18-mm-wide implants in stand-alone LLIF may increase the risk of developing high-grade subsidence necessitating reoperation compared to the use of 22-mm-wide implants.
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Formica M, Quarto E, Zanirato A, Mosconi L, Vallerga D, Zotta I, Baracchini ML, Formica C, Felli L. Lateral Lumbar Interbody Fusion: What Is the Evidence of Indirect Neural Decompression? A Systematic Review of the Literature. HSS J 2020; 16:143-154. [PMID: 32523482 PMCID: PMC7253558 DOI: 10.1007/s11420-019-09734-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the past decade, lateral lumbar interbody fusion (LLIF) has gained in popularity. A proposed advantage is the achievement of indirect neural decompression. However, evidence of the effectiveness of LLIF in neural decompression in lumbar degenerative conditions remains unclear. QUESTIONS/PURPOSES We sought to extrapolate clinical and radiological results and consequently the potential benefits and limitations of LLIF in indirect neural decompression in degenerative lumbar diseases. METHODS We conducted a systematic review of the literature in English using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. Scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain were extracted, as were data on the following radiological measurements: disc height (DH), foraminal height (FH), foraminal area (FA), central canal area (CA). RESULTS In the 42 articles included, data on 2445 patients (3779 levels treated) with a mean follow-up of 14.8 ± 5.9 months were analyzed. Mean improvements in VAS back, VAS leg, and ODI scale scores were 4.1 ± 2.5, 3.9 ± 2.2, and 21.9 ± 7.2, respectively. Post-operative DH, FH, FA, and CA measurements increased by 68.6%, 21.9%, 37.7%, and 29.3%, respectively. CONCLUSION Clinical results indicate LLIF as an efficient technique in indirect neural decompression. Analysis of radiological data demonstrates the effectiveness of symmetrical foraminal decompression. Data regarding indirect decompression of central canal and lateral recess are inconclusive and contradictory. Bony stenosis appears as an absolute contraindication. The role of facet joint degeneration is unclear. This systematic review provides a reference for surgeons to define the potential and limitations of LLIF in indirect neural elements decompression.
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Affiliation(s)
- Matteo Formica
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Emanuele Quarto
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Andrea Zanirato
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Lorenzo Mosconi
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Davide Vallerga
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Irene Zotta
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
| | | | - Carlo Formica
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, MI Italy
| | - Lamberto Felli
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, GE Italy
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Timing of Lateral Lumbar Interbody Subsidence: Review of Exclusive Intraoperative Subsidence. World Neurosurg 2020; 137:e208-e212. [DOI: 10.1016/j.wneu.2020.01.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 11/22/2022]
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Jeremy Goh KM, Liow MHL, Xu S, Yeo W, Ling ZM, Soh CCR, Tan SB, Guo CM. Reduction in foraminal height after lateral access surgery does not affect quality of life: A 2-year outcome study on lateral lumbar interbody fusion. J Orthop Surg (Hong Kong) 2020; 27:2309499019829336. [PMID: 30782071 DOI: 10.1177/2309499019829336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Reduction in neuroforaminal height (FH) may diminish the indirect decompression benefit that lateral access surgery (LAS) provides. However, the relationship between postoperative FH reduction in LAS and health-related quality-of-life (HRQoL) outcomes remains unclear. OBJECTIVES To determine whether FH reduction affects HRQoL outcomes at 2-year follow-up. METHODS A retrospective review of 45 patients who underwent LAS for degenerative lumbar spine conditions was performed. The cohort was divided into two groups: maintenance (A) and reduction (B) in FH. Outcome measures included numerical pain rating scale (NPRS back and leg pain), Oswestry Disability Index (ODI), Short Form 36 Health Survey (SF-36), North American Spine Society (NASS) score for neurogenic symptoms (NS), patient satisfaction, and expectation fulfilment for surgery. Mean disc height (DH), FH, and fusion were evaluated on plain radiographs. Radiological fusion was assessed with the Bridwell fusion classification. Unpaired student's t-test was used to compare between groups and one-way ANOVA with Bonferroni post hoc correction was used to determine differences between time intervals within each group. RESULTS The average pre-op mean FH was 16.9 ± 3.5 mm. Group A had 25 patients showing postoperative maintenance of FH (19.4 ± 3.3 mm to 20.2 ± 3.2 mm; 4% increase) at 2-year postsurgery while group B had 20 patients showing decrease in FH (21.1 ± 3.3 mm to 18.7 ± 3.5 mm; 11% decrease). Group A mean DH improved from 7.0 ± 2.0 mm to 10.3 ± 1.6 mm (47% increase). Group B mean DH improved from 6.8 ± 2.3 mm to 11.0 ± 3.0 mm (62% increase). There were no significant differences in NPRS, ODI, NASS, SF-36, and SF-36 MCS/PCS between groups at 2 years ( p > 0.05); 92% of group A and 85% of group B patients reported good satisfaction and fulfilment of expectations ( p > 0.05). CONCLUSION Despite an initial increase in FH after LAS surgery, 45% of patients had FH reduction at 2 years. However, FH reduction up to 11% did not affect short-term HRQoL outcomes.
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Affiliation(s)
| | | | - Sheng Xu
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - William Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | | | - Seang Beng Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Chang Ming Guo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Rentenberger C, Okano I, Salzmann SN, Winter F, Plais N, Burkhard MD, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Perioperative Risk Factors for Early Revisions in Stand-Alone Lateral Lumbar Interbody Fusion. World Neurosurg 2020; 134:e657-e663. [DOI: 10.1016/j.wneu.2019.10.164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 11/29/2022]
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Abstract
STUDY DESIGN An experimental laboratory-based biomechanical study. OBJECTIVE To investigate the correlation between cage size and subsidence and to quantify the resistance to subsidence that a larger cage can provide. SUMMARY OF BACKGROUND DATA The assumption that a bigger interbody cage confers less subsidence has not been proven. There was no previous study that has shown the superiority of lateral cages to bullet cages in terms of subsidence and none that has quantified the correlation between cage size and subsidence. METHODS A cage was compressed between two standardized polyurethane foam blocks at a constant speed. Four sizes of bullet cages used for transforaminal lumbar interbody fusion (TLIF) and six sizes of lateral cages used for lateral lumbar interbody fusion (LLIF) were tested. The force required for a 5 mm subsidence, axial area of cages, and stiffness were analyzed. RESULTS A larger cage required a significantly higher force for a 5 mm subsidence. Longer bullet cages required marginal force increments of only 6.2% to 14.6% compared to the smallest bullet cage. Lateral cages, however, required substantially higher increments of force, ranging from 136.4% to 235.7%. The average force of lateral cages was three times that of bullet cages (6426.5 vs. 2115.9 N), and the average stiffness of the LLIF constructs was 3.6 times that of the TLIF constructs (635.5 vs. 2284.2 N/mm). There was a strong correlation between the axial area of cages and the force for a 5 mm subsidence. Every 1 mm increment of axial area corresponded to approximately 8 N increment of force. CONCLUSION Cage size correlated strongly with the force required for a 5 mm subsidence. The LLIF constructs required higher force and were stiffer than the TLIF constructs. Among bullet cages, longer cages only required marginal increments of force. Lateral cages, however, required substantially higher force. LEVEL OF EVIDENCE N/A.
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Stinchfield T, Vadapalli S, Pennington Z, Sivagnanam R, Prevost J, Schroeder G, Sciubba DM. Improvement in vertebral endplate engagement following anterior column reconstruction using a novel expandable cage with self-adjusting, multiaxial end cap. J Clin Neurosci 2019; 67:249-254. [DOI: 10.1016/j.jocn.2019.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
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Patel DV, Yoo JS, Karmarkar SS, Lamoutte EH, Singh K. Interbody options in lumbar fusion. JOURNAL OF SPINE SURGERY 2019; 5:S19-S24. [PMID: 31380489 DOI: 10.21037/jss.2019.04.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Interbody devices have revolutionized lumbar fusion surgery by enhancing mechanical stability, optimizing sagittal parameters, and maximizing fusion potential. There are several lumbar interbody fusion approaches available for varying pathologic etiologies, surgical index levels, or due to surgeon preference. With the advancement of spinal instrumentation and interbody devices, a variety of cage materials and dimensions have been engineered to accommodate various lumbar fusion approaches. The efficacy of a fusion is dependent on the shape, size, and material makeup of that interbody device. Since there are numerous cages available in today's market, it is important to find the optimal cage to best accommodate specific lumbar fusion cases. This review will explain the properties and future advancements of various interbody devices available for lumbar fusions.
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Affiliation(s)
- Dil V Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Cage Subsidence and Fusion Rate in Extreme Lateral Interbody Fusion with and without Fixation. World Neurosurg 2019; 122:e969-e977. [DOI: 10.1016/j.wneu.2018.10.182] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 11/19/2022]
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Subsidence Rates After Lateral Lumbar Interbody Fusion: A Systematic Review. World Neurosurg 2018; 122:599-606. [PMID: 30476670 DOI: 10.1016/j.wneu.2018.11.121] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/14/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The evidence regarding the consequences of subsidence with lateral lumbar interbody fusion (LLIF) has been sparse. The objective of this study is to calculate the incidence of subsidence and reoperation for subsidence after LLIF. A secondary outcome examined the quantitative degree of subsidence by calculating the percent change in the height of the intervertebral space secondary to interbody subsidence at various postoperative follow-up times. METHODS Following the MOOSE (Meta-analysis [and Systematic Review] Of Observational Studies in Epidemiology) guidelines, a systematic review searched for all cohort studies that focused on subsidence rates after LLIF, including extreme lateral interbody fusions (XLIFs) and direct lateral interbody fusion. Neoplastic, infectious, and/or metabolic indications for LLIF were similarly excluded because these diseases may compromise bone quality and, thus, confound the rate of cage subsidence. Corpectomies were removed from the systematic review because 1) indications for removal of vertebral body typically reflect those excluded diseases and 2) subsidence refers to a different biomechanical process. RESULTS This systematic review identified a subsidence incidence with LLIF of 10.3% (N = 141/1362 patients in 14 articles) and reoperation rate for subsidence of 2.7% (N = 41/1470 patients in 16 articles). In the secondary outcome measure, the disc height decreased from 5.6% after 3 months, 6.0% after 6 months, and 10.2% after 12 months, to 8.9% after 24 months (P < 0.001). CONCLUSIONS Subsidence after LLIF carries a nonnegligible risk that may be incorporated in surgical consent discussions in selected patients.
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Head JR, Rymarczuk GN, He KD, Harrop JS. Delayed hardware complication after lateral retroperitoneal lumbar surgery: an unusual case of painless hematuria. J Neurosurg Spine 2018; 29:541-544. [PMID: 30168783 DOI: 10.3171/2018.5.spine171259] [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: 11/17/2017] [Accepted: 05/07/2018] [Indexed: 11/06/2022]
Abstract
Lateral approaches to the spine are becoming increasingly popular methods for decompression, restoration of alignment, and arthrodesis. Although individual cases of intraoperative injuries to the renal vasculature and the ureters have been documented as rare complications of lateral approaches to the spine, the authors report the first known case of postoperative renal injury due to the delayed extrusion of the screw of a lateral plate/screw construct directly into the renal parenchyma. The migration of the screw from the L1 vertebra into the superior pole of the left kidney occurred nearly 5 years after the index procedure, and presented as painless hematuria. A traditional left-sided retroperitoneal approach had been used at the time of the initial surgery, and the same exposure was used to remove the hardware, which was done in conjunction with general surgery and urology.
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Affiliation(s)
- Jeffery R Head
- 1Sidney Kimmel Medical College and
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - George N Rymarczuk
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
- 3Divison of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kevin D He
- 1Sidney Kimmel Medical College and
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - James S Harrop
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
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He L, Xie P, Shu T, Liu Z, Feng F, Chen Z, Chen R, Zhang L, Rong L. Clinical and Radiographic Results of a Minimally Invasive Lateral Transpsoas Approach for Treatment of Septic Spondylodiscitis of the Thoracolumbar and Lumbar Spine. World Neurosurg 2018; 116:e48-e56. [PMID: 29626684 DOI: 10.1016/j.wneu.2018.03.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The minimally invasive lateral transpsoas approach allows retroperitoneal access for discectomy and graft placement. However, the procedure has rarely been used for the treatment of septic spondylodiscitis. The purposes of this study were to evaluate the clinical and radiographic outcomes from this minimally invasive procedure for septic spondylodiscitis. METHODS Thirty-one consecutive patients (17 males and 14 females) were included in this study from July 2013 to January 2016. Clinical outcomes were assessed by Oswestry Disability Index, visual analog scale, modified Macnab criteria, and inflammatory parameters. Radiographic results were analyzed by studying the changes in diseased disc height, lordosis, and fusion status. RESULTS The Oswestry Disability Index and visual analog scale score improved by 58% and 69% at the last follow-up. The modified Macnab criteria were found to be excellent in 21 patients (68%) and good in 10 (32%). Inflammatory parameters normalized over the average 24 months follow-up. There were no major complications that might have influenced the outcomes in this cohort. A complete fusion after 12 months was achieved in 87% of patients. A mean 7.5 mm restoration in disc height and 6.4° restoration in lumbar lordosis were observed in all patients, whereas an average 4.5 mm loss in restored height resulting from graft subsidence was observed in 24 patients during the follow-up. However, graft subsidence did not influence clinical outcomes significantly. CONCLUSIONS A minimally invasive lateral transpsoas approach in combination with instrumentation provides a novel treatment for patients with septic spondylodiscitis without severe kyphosis and neurologic impairment.
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Affiliation(s)
- Lei He
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peigen Xie
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tao Shu
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongyu Liu
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Feng Feng
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zihao Chen
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruiqiang Chen
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liangming Zhang
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Limin Rong
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Xu DS, Walker CT, Godzik J, Turner JD, Smith W, Uribe JS. Minimally invasive anterior, lateral, and oblique lumbar interbody fusion: a literature review. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:104. [PMID: 29707553 DOI: 10.21037/atm.2018.03.24] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lumbar interbody fusion involves insertion of a structural graft into an intervertebral disc space to promote bony arthrodesis. It is a well-established surgical strategy for multiple spinal disorders ranging from degenerative conditions to trauma, neoplastic diseases, and deformities requiring correction. Since the inception of lumbar interbody fusion, the most established techniques have been two posterior approaches, the posterior lumbar interbody fusion (PLIF) and the transforaminal lumbar interbody fusion (TLIF). Within the past 15 years, multiple anterolateral approaches to the spine have become widely adopted. These approaches can be performed minimally invasively and spare disruption of the paraspinal muscles and posterior spinal column while enabling wide exposure of the disc space for insertion of interbody grafts much larger than PLIF and TLIF instrumentation. This review highlights three minimally invasive anterolateral approaches: the anterior lumbar interbody fusion (ALIF), the transpsoas lateral lumbar interbody fusion (LLIF), and prepsoas or anterior to the psoas oblique lumbar interbody fusion (OLIF). Relevant topics for discussion and comparison include patient selection, surgical techniques, outcomes, and complications for the three surgical approaches.
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Affiliation(s)
- David S Xu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - William Smith
- Department of Neurosurgery, University Medical Center, Las Vegas, Nevada, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Janssen I, Lang G, Navarro-Ramirez R, Jada A, Berlin C, Hilis A, Zubkov M, Gandevia L, Härtl R. Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures? World Neurosurg 2017; 107:322-333. [DOI: 10.1016/j.wneu.2017.07.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW Lateral lumbar interbody fusion (LLIF) is a relatively new, minimally invasive technique for interbody fusion. The goal of this review is to provide a general overview of LLIF with a special focus on outcomes and complications. RECENT FINDINGS Since the first description of the technique in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications.
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Affiliation(s)
- Stephan N Salzmann
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
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