Outcomes of Two Different Techniques Using the Lateral Approach for Lumbar Interbody Arthrodesis

Sequential Depth Stimulation Within the Psoas Offers No Benefit for Localization of the Lumbar Plexus During Lateral Lumbar Fusion Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

In this study we aim to assess the difference in triggered EMG readings throughout different depths in the psoas muscle during the lateral approach to the lumbar spine and their effect on surgeon decision making.

METHODS

Three surgeons, practicing at different institutions, assessed triggered EMG readings during the trans psoas approach at the level of the disc and 5,10 and 15 millimeters into the psoas muscle with sequential dilators. Measurement of distance into the psoas muscle was done with a specially designed instrument. Results of anterior and posterior directed stimulation as well as the delta value between these were recorded and underwent statistical analysis. Patients who had partial readings were excluded from the study.

RESULTS

A total of 40 levels in 35 patients were included in the study. There was no significant difference found between means of anterior or posterior threshold readings along the different distance groups. A significant difference was found (P = .024) in the mean difference between the distance groups with a decrease in the difference between anterior and posterior threshold values found as the distance from the disc space increased. None of the surgeons reported a decision to abort the fusion of a spinal level.

CONCLUSIONS

In the trans-psoas approach to the lumbar spine, the assessment of the location of the femoral nerve using directional neuromonitoring when advancing in the psoas muscle shows no clear benefit as opposed to stimulating solely when adjacent to the disc space.

Prone Transpsoas Lateral Interbody Fusion (PTP LIF) with Anterior Docking: Preliminary functional and radiographic outcomes

Background

Disadvantages of lateral interbody fusion (LIF) through a direct, transpsoas approach include difficulties associated with lateral decubitus positioning and limited sagittal correction without anterior longitudinal ligament release or posterior osteotomy. Prior technical descriptions advocate anchoring or docking the retractor into the posterior to middle aspect of the disc space.

Methods

72 patients who underwent 116 total levels of Prone Transpsoas (PTP) LIF with anterior docking with a single surgeon between December 2021 and May 2023 were included. Patient characteristics, perioperative data, as well as postoperative functional and radiographic outcomes were recorded. Subgroup analysis was performed for patients who underwent single-level PTP LIF with single-level percutaneous fixation (SLP). Patients in the SLP subgroup did not undergo direct decompression, release, or osteotomy.

Results

N=41 (56.9%) of cases included the L4-5 level. No vascular, bowel, or other visceral complications occurred. No patients developed a permanent motor deficit. Both the total cohort and the SLP group demonstrated statistically significant improvements in functional outcomes including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) as well as all radiographic parameters measured. Mean total operative time (incision to completion of closure for lateral and posterior fusion) in the SLP group was 104.3 minutes with a significant downward trend with increasing surgeon experience. The SLP group demonstrated a 9.9° increase in segmental lordosis (SL), a 7.5° increase in lumbar lordosis (LL), 5.3° reduction in pelvic tilt (PT), and a decrease in pelvic incidence - lumbar lordosis mismatch (PI-LL) from 11.0° preoperatively to 3.9°, postoperatively (p<.01).

Conclusions

PTP LIF with anterior docking may address shortcomings associated with traditional lateral interbody fusion by producing safe and reproducible access with improved restoration of segmental lordosis and optimization of spinopelvic parameters.

Comparison of surgical outcomes between oblique lateral interbody fusion (OLIF) and anterior lumbar interbody fusion (ALIF)

OBJECTIVE

Although oblique lateral interbody fusion (OLIF) utilizes the similar approach in anterior lumbar interbody fusion (ALIF), OLIF is essentially a lateral lumbar interbody fusion (LLIF). Therefore, OLIF may have advantages in LLIF that the lateral cage can achieve greater restoration of the disc height and angle. We aimed to compared the surgical outcomes between OLIF and ALIF.

METHODS

This study involved 47 consecutive patients who underwent a single-level OLIF and 45 consecutive patients who underwent a single-level ALIF at L2-L5 levels. Radiological measurements included the changes of anterior/posterior disc height, coronal/sagittal disc angle, foramen cross-sectional area (CSA), cage position from the anterior margin of the lower vertebra, fusion rate, and cage subsidence using the serial radiographs and computed tomography preoperatively and at the postoperative 1-year follow-up. Clinical outcomes were assessed by visual analog scale (VAS) for back/leg pain, Oswestry disability index (ODI), and the occurrence of perioperative complications.

RESULTS

The baseline radiological and clinical parameters were similar between the OLIF and ALIF groups (all P > 0.05). At postoperative 1 year, the mean anterior disc height was higher in the OLIF group than the ALIF group (11.4 ± 1.9 mm vs. 9.6 ± 2.6 mm, P = 0.021). The mean sagittal disc angle was also greater in the OLIF group than the ALIF group (10.9 ± 4.4° vs. 8.9 ± 5.8°, P < 0.001). The mean cage position was 5.8 ± 2.1 mm in the OLIF group and 8.7 ± 2.3 mm in the ALIF group (P <  0.001). There was no difference in the postoperative changes of coronal disc angles, foramen CSA, fusion rate, cage subsidence, VAS for back/leg pain, ODI, and the occurrence of perioperative complications between the OLIF and ALIF groups (all P > 0.05).

CONCLUSIONS

OLIF showed a greater increase in disc height and segmental lordosis than ALIF with comparable complications. OLIF is a meaningful progress from ALIF.

Intraoperative Neuromonitoring and Lumbar Spinal Instrumentation: Indications and Utility

Multimodal intraoperative neurophysiologic monitoring (IONM) can be utilized as an adjunct to lumbar spinal instrumentation in order to aid with avoidance of neurologic complications. The most commonly utilized modalities include somatosensory-evoked potentials, motor-evoked potentials, and electromyography. Somatosensory-evoked potentials (SSEPs) allow for continuous assessment of the dorsal columns of the spinal cord and are therefore most useful during procedures with a posterior approach to the cervical and thoracic spine. Motor-evoked potentials (MEPs) and electromyography (EMG) can be applied intermittently to assess motor nerve function. The utility of each individual modality can be largely dependent on the surgical approach. Approaches to lumbar spinal instrumentation can be generally categorized as anterior, lateral, and posterior. For lateral approaches, electromyography can be helpful in identifying neural structures crossing the surgical field to prevent injury. In posterior and anterior approaches, somatosensory-evoked potentials and motor-evoked potentials can be used to assess nerve injury during and after maneuvers for decompression and instrumentation. Additionally, during the placement of pedicle screws, direct stimulation with triggered electromyography can be used to detect the pedicle cortex's breach. The efficacy of intraoperative neuromonitoring is dependent on prompt and accurate recognition of changes in signals. This is then followed by accurate recognition of the cause for these changes and appropriate responses by the surgeon, anesthesiologist, and monitoring personnel to correct the change.

Factors Influencing Early Disc Height Loss Following Lateral Lumbar Interbody Fusion

Study Design

Retrospective radiological analysis.

Purpose

To analyze the factors influencing early disc height loss following lateral lumbar interbody fusion (LLIF).

Overview of Literature

Postoperative disc height loss can occur naturally as a result of mechanical loading. This phenomenon is enabled by the yielding of the polyaxial screw heads and settling of the cage to the endplates. When coupled with cage subsidence, there can be significant reduction in the foraminal space which ultimately compromises the indirect decompression achieved by LLIF.

Methods

Seventy-two cage levels in 37 patients aged 62±10.2 years who underwent single or multilevel LLIF for degenerative spinal conditions were selected. Their preoperative and postoperative follow-up radiographs were used to measure the anterior disc height (ADH), posterior disc height (PDH), mean disc height (MDH), disc space angle (DSA), and segmental angle. Correlations between the loss of disc height and several factors, including age, construct length, preoperative lordosis, postoperative lordosis, disc height, cage dimensions, and cage position, were analyzed.

Results

We found that the lateral interbody cages significantly increased ADH, PDH, MDH, and DSA after surgery (p <0.0001). However, there was a loss of disc height over time. All postoperative disc height parameters, especially the amount of increase in MDH (r =0.413, p <0.0001) after surgery, showed a significant positive association with early disc height loss. The levels demonstrating a significant (≥25%) height loss were those that exhibited a substantial height increase (128.3%, 4.6±3.0 to 10.5±5.6 mm) postoperatively. However, the levels that showed less than 25% height loss were those that exhibited, on average, only a 57.4% height increase post-operatively.

Conclusions

The greater the postoperative increase in disc height, the greater the disc height loss throughout early follow-up. Therefore, achieving an optimal disc height rather than overcorrection is an important surgical strategy to adopt when performing LLIF.

The effect of vascular approach surgeons on perioperative complications in lateral transpsoas lumbar interbody fusions

BACKGROUND CONTEXT

Lateral lumbar interbody fusion (LLIF) is a popular technique used in spine surgery. It is minimally invasive, provides indirect decompression, and allows for coronal plane deformity correction. Despite these benefits, the approach to LLIF has been linked to complications associated with the lumbosacral plexus and vascular anatomy. As a result, vascular surgeons may be recruited for the exposure portion of the procedure.

PURPOSE

The purpose of this study was to compare exposure-related complication and postoperative (postop) neuropraxia rates between exposure (EXP) and spine surgeon only (SSO) groups while performing the approach for LLIF.

STUDY DESIGN/SETTING

Retrospective analysis of patients treated at a single institution.

PATIENT SAMPLE

Patients undergoing LLIF procedures between 2012 and 2018.

OUTCOME MEASURES

Operative time, estimated blood loss, fluoroscopy, length of stay (LOS), intra- and postoperative complications, and physiologic measures including pre- and postoperative motor examinations and unresolved neuropraxia.

METHODS

Patients who underwent LLIF were separated into EXP and SSO groups based on the presence or absence of vascular/general surgeon during the approach. The entire clinical history of patients with a decrease in pre- and postop motor examination was reviewed for the presence of neuropraxia. All other intra- and postop exposure-related complications were recorded for comparison. Propensity score matching (PSM) was performed to account for age, Charlson Comorbidity Index (CCI) percentage of LLIFs including L4-L5, and number of levels fused. Independent t test and chi-square analyses were used to identify significant differences between EXP and SSO groups. Statistical significance was set at p<.05.

RESULTS

Two hundred and seventy-five patients underwent LLIF procedures, 155 SSO and 120 EXP. Postoperatively, 26 patients (11.1%) experienced a drop in any Medical Research Council (MRC) score, and two patients (0.7%) experienced unresolved quadriceps palsies. The mean recovery time for MRC scores was 84.4 days. Other complications included 2 pneumothoraces (0.7%), 1 iliac vein injury (0.4%), 14 cases of ileus (5.1%), 3 pulmonary emboli (1.1%), 2 deep vein thrombosis (0.7%), 3 cases of abdominal wall paresis (1.1%), and one abdominal hematoma (0.4%). After PSM, demographics including age, gender, body mass index, CCI, levels fused, and operative time were similar between cohorts. Twenty patients had changes in pre- to postop motor scores (SSO 9.4%, EXP 12.4%, p>.05). Iliopsoas motor scores decreased at the highest rate (EXP 12.4%, SSO 8.2%, p>.05) followed by quadriceps (EXP 5.2%, SSO 4.7%, p>.05). One SSO patient's postop course was complicated by a foot drop but returned to baseline within 1 year. One patient in EXP group developed an unresolved quadriceps palsy (EXP 1.0%, SSO 0.0%, p>.05). Intraoperative exposure complications included one pneumothorax (EXP 1.0%, SSO 0.0%, p>.05). There were no differences in PE/DVT, Ileus, or LOS. In the EXP cohort, three patients experienced abdominal wall paresis (EXP 2.9%, SSO 0.00%, p=.246).

CONCLUSIONS

Comparing the LLIF exposures performed by EXP and SSO, we found no significant difference in the rates of complications. Additional research is needed to determine the etiology of the abdominal wall complications. In conclusion, neuropraxia- and approach-related complications are similarly low between exposure and spine surgeons.

Diffusion tensor tractography of the lumbar nerves before a direct lateral transpsoas approach to treat degenerative lumbar scoliosis

OBJECTIVE

The purpose of this study was to determine the relationship between vertebral bodies, psoas major morphology, and the course of lumbar nerve tracts using diffusion tensor imaging (DTI) before lateral interbody fusion (LIF) to treat spinal deformities.

METHODS

DTI findings in a group of 12 patients (all women, mean age 74.3 years) with degenerative lumbar scoliosis (DLS) were compared with those obtained in a matched control group of 10 patients (all women, mean age 69.8 years) with low-back pain but without scoliosis. A T2-weighted sagittal view was fused to tractography from L3 to L5 and separated into 6 zones (zone A, zones 1-4, and zone P) comprising equal quarters of the anteroposterior diameters, and anterior and posterior to the vertebral body, to determine the distribution of nerves at various intervertebral levels (L3-4, L4-5, and L5-S1). To determine psoas morphology, the authors examined images for a rising psoas sign at the level of L4-5, and the ratio of the anteroposterior diameter (AP) to the lateral diameter (lat), or AP/lat ratio, was calculated. They assessed the relationship between apical vertebrae, psoas major morphology, and the course of nerve tracts.

RESULTS

Although only 30% of patients in the control group showed a rising psoas sign, it was present in 100% of those in the DLS group. The psoas major was significantly extended on the concave side (AP/lat ratio: 2.1 concave side, 1.2 convex side). In 75% of patients in the DLS group, the apex of the curve was at L2 or higher (upper apex) and the psoas major was extended on the concave side. In the remaining 25%, the apex was at L3 or lower (lower apex) and the psoas major was extended on the convex side. Significant anterior shifts of lumbar nerves compared with controls were noted at each intervertebral level in patients with DLS. Nerves on the extended side of the psoas major were significantly shifted anteriorly. Nerve pathways on the convex side of the scoliotic curve were shifted posteriorly.

CONCLUSIONS

A significant anterior shift of lumbar nerves was noted at all intervertebral levels in patients with DLS in comparison with findings in controls. On the convex side, the nerves showed a posterior shift. In LIF, a convex approach is relatively safer than an approach from the concave side. Lumbar nerve course tracking with DTI is useful for assessing patients with DLS before LIF.

Accuracy of the lateral cage placement under intraoperative C-arm fluoroscopy in oblique lateral interbody fusion

BACKGROUND

In oblique lateral interbody fusion (OLIF), the lateral cage enters into the disc space obliquely, and is then turned to the true lateral direction to achieve a lateral lumbar interbody fusion. The OLIF cage is sometimes placed asymmetrically although it seemed to be placed accurately on intraoperative C-arm images. The present study aimed to investigate the accuracy of cage placement and its effect on the radiological outcome in OLIF.

METHODS

This study involved a retrospective radiological analysis of 127 lateral cages in 75 consecutive OLIF patients. The cage deviations from the midline and cage obliquity were evaluated using three sets of images: (1) intraoperative C-arm fluoroscopy, (2) postoperative standing radiographs, and (3) postoperative computed tomography (CT).

RESULTS

The mean cage deviation from the midline was measured as 2.5 ± 2.7 mm on intraoperative C-arm images, but was found to be more deviated on postoperative radiographs and CT (5.4 ± 3.8 mm and 3.8 ± 3.7 mm; P = 0.000 and 0.005, respectively). The cage obliquity on the intraoperative lateral C-arm was minimal in 26 (20.5%) cases, mild in 69 (54.3%), and moderate in 32 (25.2%), but was found to be more obliquely on postoperative radiographs as minimal in 9 (7.1%), mild in 55 (43.3%), and moderate in 63 (49.6%) (P < 0.001). Anterior/posterior disc heights, disc lordotic angle, fusion rate, and cage subsidence rate were not different according to cage obliquity (all P > 0.05).

CONCLUSIONS

Cage deviation from the midline and obliquity is underestimated on intraoperative C-arm images in OLIF. Although minimal cage deviation and obliquity did not affect the radiological outcome, great care should be made for the orthogonal cage insertion.

Neurologic adverse event avoidance in lateral lumbar interbody fusion: technical considerations using muscle relaxants

Background

The retroperitoneal trans-psoas extreme lateral interbody fusion (XLIF) technique has improved over the last decade with increased efficiency and an emphasis on complication avoidance. After all known procedural safeguards are enacted, the most common failure of neuro-monitoring precision may be the use of non-depolarizing muscle relaxants (MR) for induction that is standard of care for anesthesia. Even when non-depolarizing MRs are minimized there is often a small dose given to decrease risk of vocal cord injury with intubation. The most common neurological adverse events (AE) attendant to the lateral approach are thigh dysesthetic pain and hip flexor weakness. The purpose of this study is to present a consecutive series of L3-4 and L4-5 XLIF patients treated by a single surgeon using all procedural safeguards with and without the use of a low dose of non-depolarizing MRs prior to intubation.

Methods

A retrospective review of 74 consecutive patients treated at 150 levels with XLIF and no muscle relaxants (NMR) were compared to a group of 124 consecutive XLIF patients treated at 238 levels with MR. The surgeon upon discovering a small dose of rocuronium was used for intubation, questioned the effect on the neuromonitoring and NMR group was begun. All procedural technique details remained the same. All patients had XLIF at L3-4, L4-5, or both levels. Perioperative variables were collected, including evoked and free-run EMG readings and postoperative neural and muscular side effects. Hospital records including progress notes describing postoperative symptoms and anesthesia records describing the drugs, dosages, and timing were studied. Clinical records were reviewed at 1, 3 and 6 months for complaints of neurologic AE.

Results

NMR patients had a perfect twitch test (>99%) immediately. MR patients had slower arrival of the twitch and often settled at a lower level (80-92%). No surgery was attempted until the twitch test was at least 80%. NMR had 8/74 (10.8%) and MR 36/125 (28.8%) thigh AE (thigh dysthetic pain) at 1 month (P<0.005). No lower extremity weaknesses (femoral nerve injury) were observed in the NMR group and three in the MR group. All NMR thigh AEs resolved by the third month postoperative visit compared with 17/125 at 3 months (P=0.001) and 6/125 at 6 months (P=0.176) with persistent thigh AEs in the MR group.

Conclusions

Eliminating MRs altogether appears to have allowed the evoked and free running EMG to be more reliable and accurate in predicting the proximity of the neurologic structures. Thigh AEs related to neural and muscular integrity in NMR patients were limited and eliminated by the 3rd month. The MR group was significantly more likely to have a thigh AE at 1 month and persistent at 3 months. Neurologic AEs may be limited or eliminated when MRs are avoided in lateral lumbar fusion surgery.

Minimally Invasive Far Lateral Lumbar Interbody Fusion: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To assess rate and degree of interbody bone fusion and evolution in Oswestry Disability index (ODI) and visual analog scale (VAS) of pain after minimally invasive far lateral lumbar interbody fusion.

METHODS

Twenty-three patients with single-level lumbar instability or degenerative disc were treated by this method and prospectively included. VAS of pain and ODI were evaluated preoperatively and at last follow-up. Computed tomography scan was performed 6 months after surgery to assess interbody fusion.

RESULTS

Between preoperative and 2 years postoperative follow-up, mean VAS decreased by 2.4 points (P < .001); mean ODI improved by 21.8% (P < .001). Computed tomography scan showed fusion in all patients but one. No severe complications were observed.

CONCLUSIONS

Minimally invasive far lateral lumbar interbody fusion resulted in satisfactory clinical and radiological results.

[Results of surgical treatment for lumbar spine segmental instability]

AIM

To perform a comparative analysis of outcomes in patients with lumbar spine segmental instability who underwent surgical treatment using transforaminal lumbar interbody fusion (TLIF) and direct lateral interbody fusion (DLIF) techniques.

MATERIAL AND METHODS

The multicenter study involved 209 patients who underwent surgery for lumbar spine segmental instability. Long-term outcomes (up to 2 years) were studied in 134 patients: patients of the first group (98 patients) underwent traditional transforaminal lumbar interbody fusion (TLIF) and transpedicular stabilization of vertebral segments; patients of the second group (36 patients) underwent direct lateral interbody fusion (DLIF) in combination with transpedicular stabilization of the lumbar vertebral segments. We used standard checkpoints for monitoring the patients' condition: before surgery, at discharge, at 3, 6 and, 9 months, and at 1 and 2 years after surgery. To follow-up the patients, we used the Visual Analogue Scale, Oswestry Disability Index, and Goal Attainment Scaling.

RESULTS

A comparative analysis of the two interbody fusion techniques was enabled by the developed Vertebrologic Registry profile (http://spineregistry.ru/Register_treatment.php) that was designed for entering data of Russian and foreign experts to analyze clinical characteristics, evaluate outcomes, and follow-up patients with degenerative lumbosacral spine diseases. In both groups of patients, a significant decrease in the pain intensity in the lumbar spine and lower extremities (VAS) occurred in the immediate postoperative period, which persisted in the long-term period. There were no differences in the disability level (Oswestry index) in both groups of patients (p<0.05). An analysis of treatment goal attainments one year after surgery revealed the best result in patients of the second group who underwent DLIF.

CONCLUSIONS

1. Indirect decompression using direct lateral interbody fusion (DLIF) minimizes the risks of intraoperative injury to the dura mater and neural structures. Kawabata class I outcomes (good) were achieved in 89% of patients who underwent direct lateral spinal fusion (DLIF) and in 81% of patients who underwent transforaminal interbody stabilization in combination with transpedicular fixation.

Anatomical evaluation of lumbar nerves using diffusion tensor imaging and implications of lateral decubitus for lateral transpsoas approach

PURPOSE

Recently, lateral interbody fusion (LIF) has become more prevalent, and evaluation of lumbar nerves has taken on new importance. We report on the assessment of anatomical relationships between lumbar nerves and vertebral bodies using diffusion tensor imaging (DTI).

METHODS

Fifty patients with degenerative lumbar disease and ten healthy subjects underwent DTI. In patients with lumbar degenerative disease, we studied nerve courses with patients in the supine positions and with hips flexed. In healthy subjects, we evaluated nerve courses in three different positions: supine with hips flexed (the standard position for MRI); supine with hips extended; and the right lateral decubitus position with hips flexed. In conjunction with tractography from L3 to L5 using T2-weighted sagittal imaging, the vertebral body anteroposterior span was divided into four equally wide zones, with six total zones defined, including an anterior and a posterior zone (zone A, zones 1-4, zone P). We used this to characterize nerve courses at disc levels L3/4, L4/5, and L5/S1.

RESULTS

In patients with degenerative lumbar disease, in the supine position with hips flexed, all lumbar nerve roots were located posterior to the vertebral body centers in L3/4 and L4/5. In healthy individuals, the L3/4 nerve courses were displaced forward in hips extended compared with the standard position, whereas in the lateral decubitus position, the L4/5 and L5/S nerve courses were displaced posteriorly compared with the standard position.

CONCLUSIONS

The L3/4 and L4/5 nerve roots are located posterior to the vertebral body center. These were found to be offset to the rear when the hip is flexed or the lateral decubitus position is assumed. The present study is the first to elucidate changes in the course of the lumbar nerves as this varies by position. The lateral decubitus position or the position supine with hips flexed may be useful for avoiding nerve damage in a direct lateral transpsoas approach. Preoperative DTI seems to be useful in evaluating the lumbar nerve course as it relates anatomically to the vertebral body.

High neurological complication rates for extreme lateral lumbar interbody fusion and related techniques: A review of safety concerns

BACKGROUND

There are frequent reports of lumbosacral plexus and other neurological injuries occurring with extreme lateral interbody fusions (XLIF) and other related lateral lumbar techniques.

METHODS

This review focuses on the new neurological deficits (e.g. lumbosacral plexus, root injuries) that occur following minimally invasive surgery (MIS) XLIF and other related lateral lumbar techniques.

RESULTS

A review of multiple articles revealed the following ranges of new postoperative neurological complications for XLIF procedures: plexus injuries 13.28%; sensory deficits 0-75% (permanent in 62.5%); motor deficits 0.7-33.6%; anterior thigh pain 12.5-25%. Of interest, in a study by Lykissas et al., the frequency of long-term neural injury following lateral lumber interbody fusion (LLIF) with BMP-2 (72 patients) was much higher than for LLIF performed with autograft/allograft (72 patients). The addition of bone morphogenetic protein led to persistent sensory deficits in 29 vs. 20 without BMP; persistent motor deficits in 35 with vs. 17 without BMP; and persistent anterior thigh/groin pain in 8 with vs. 0 without BMP. They should also have noted the unacceptably high incidence of neural injury occurring with LLIF alone without BMP.

CONCLUSION

This review highlights the high risk of neural injury (up to 75% for sensory, 33.6% for motor, and an overall plexus injury rate of 13.28%) utilizing the XLIF and other similar lateral lumbar approaches. With such extensive neurological injuries, is the XLIF really safe, and should it still be performed?

Operative Management of Lumbar Degenerative Disc Disease

Lumbar degenerative disc disease is extremely common. Current evidence supports surgery in carefully selected patients who have failed non-operative treatment and do not exhibit any substantial psychosocial overlay. Fusion surgery employing the correct grafting and stabilization techniques has long-term results demonstrating successful clinical outcomes. However, the best approach for fusion remains debatable. There is some evidence supporting the more complex, technically demanding and higher risk interbody fusion techniques for the younger, active patients or patients with a higher risk of non-union. Lumbar disc arthroplasty and hybrid techniques are still relatively novel procedures despite promising short-term and mid-term outcomes. Long-term studies demonstrating superiority over fusion are required before these techniques may be recommended to replace fusion as the gold standard. Novel stem cell approaches combined with tissue engineering therapies continue to be developed in expectation of improving clinical outcomes. Results with appropriate follow-up are not yet available to indicate if such techniques are safe, cost-effective and reliable in the long-term.