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Lewandrowski KU, Vira S, Elfar JC, Lorio MP. Advancements in Custom 3D-Printed Titanium Interbody Spinal Fusion Cages and Their Relevance in Personalized Spine Care. J Pers Med 2024; 14:809. [PMID: 39202002 PMCID: PMC11355268 DOI: 10.3390/jpm14080809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/17/2024] [Accepted: 07/24/2024] [Indexed: 09/03/2024] Open
Abstract
3D-printing technology has revolutionized spinal implant manufacturing, particularly in developing personalized and custom-fit titanium interbody fusion cages. These cages are pivotal in supporting inter-vertebral stability, promoting bone growth, and restoring spinal alignment. This article reviews the latest advancements in 3D-printed titanium interbody fusion cages, emphasizing their relevance in modern personalized surgical spine care protocols applied to common clinical scenarios. Furthermore, the authors review the various printing and post-printing processing technologies and discuss how engineering and design are deployed to tailor each type of implant to its patient-specific clinical application, highlighting how anatomical and biomechanical considerations impact their development and manufacturing processes to achieve optimum osteoinductive and osteoconductive properties. The article further examines the benefits of 3D printing, such as customizable geometry and porosity, that enhance osteointegration and mechanical compatibility, offering a leap forward in patient-specific solutions. The comparative analysis provided by the authors underscores the unique challenges and solutions in designing cervical, and lumbar spine implants, including load-bearing requirements and bioactivity with surrounding bony tissue to promote cell attachment. Additionally, the authors discuss the clinical outcomes associated with these implants, including the implications of improvements in surgical precision on patient outcomes. Lastly, they address strategies to overcome implementation challenges in healthcare facilities, which often resist new technology acquisitions due to perceived cost overruns and preconceived notions that hinder potential savings by providing customized surgical implants with the potential for lower complication and revision rates. This comprehensive review aims to provide insights into how modern 3D-printed titanium interbody fusion cages are made, explain quality standards, and how they may impact personalized surgical spine care.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Division Personalized Pain Research and Education, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas Bogotá, Bogotá 111321, Colombia
| | - Shaleen Vira
- Orthopedic and Sports Medicine Institute, Banner-University Tucson Campus, 755 East McDowell Road, Floor 2, Phoenix, AZ 85006, USA;
| | - John C. Elfar
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Tucson, AZ 85721, USA
| | - Morgan P. Lorio
- Advanced Orthopedics, 499 East Central Parkway, Altamonte Springs, FL 32701, USA;
- Orlando College of Osteopathic Medicine, Orlando, FL 34787, USA
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Schlesinger SM, Maggio D, Lorio MP, Lewandrowski KU, Block JE. Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 2: Assessment of Surgical Safety in Medicare Beneficiaries. J Pers Med 2023; 13:jpm13030566. [PMID: 36983747 PMCID: PMC10056390 DOI: 10.3390/jpm13030566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
(1) Background: The clinical benefits and procedural efficiencies of performing minimally invasive fusion procedures, such as transforaminal lumbar interbody fusion (TLIF), in the ambulatory surgery center (ASC) are becoming increasingly well established. Currently, Medicare does not provide reimbursement for its beneficiaries eligible for TLIF in the ASC due to a lack of evidence regarding procedural safety. However, the initiation of the Hospital Without Walls program allowed for traditional hospital procedures to be relocated to other facilities such as ASCs, providing a unique opportunity to evaluate the utility of TLIF in the ASC in Medicare-age patients. (2) Methods: This single-center, retrospective study compared baseline characteristics, intraoperative variables, and 30-day postoperative safety outcomes between 48 Medicare-age patients undergoing TLIF in the ASC and 48 patients having the same procedure as hospital in-patients. All patients had a one-level TLIF using the VariLift®-LX expandable lumbar interbody fusion device. (3) Results: There were similar patient characteristics, procedural efficiency, and occurrence of clinical 30-day safety events between the two study groups. However, there was a marked and statistically significant difference in the median length of stay favoring TLIF patients treated in the ASC (23.9 h vs. 1.6 h, p = 0.001). All ASC-treated patients were discharged on the day of surgery. Postoperative visits to address adverse events were rare in either group. (4) Conclusions: These findings provide evidence that minimally invasive TLIF can be performed safely and efficiently in the ASC in Medicare-age patients. With same-day discharge, fusion procedures performed in the ASC offer a similar safety and more attractive cost-benefit profile for older patients than the same surgery undertaken in the traditional hospital setting. The Centers for Medicare and Medicaid Services should strongly consider extending the appropriate reimbursement codes (CPT ® 22630, 22633) for minimally invasive TLIF and PLIF to the ASC Covered Procedure List so that Medicare-age patients can realize the clinical benefits of surgeries performed in this setting.
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Affiliation(s)
- Scott M Schlesinger
- Legacy Spine & Neurological Specialists, 8201 Cantrell Rd., Ste. 265, Little Rock, AR 72227, USA
| | - Dominic Maggio
- Legacy Spine & Neurological Specialists, 8201 Cantrell Rd., Ste. 265, Little Rock, AR 72227, USA
| | - Morgan P Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, 4787 E., Camp Lowell Drive, Tucson, AZ 85712, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
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Biomechanical and clinical studies on lumbar spine fusion surgery: a review. Med Biol Eng Comput 2023; 61:617-634. [PMID: 36598676 DOI: 10.1007/s11517-022-02750-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023]
Abstract
Low back pain is associated with degenerative disc diseases of the spine. Surgical treatment includes fusion and non-fusion types. The gold standard is fusion surgery, wherein the affected vertebral segment is fused. The common complication of fusion surgery is adjacent segment degeneration (ASD). The ASD often leads to revision surgery, calling for a further fusion of adjacent segments. The existing designs of nonfusion type implants are associated with clinical problems such as subsidence, difficulty in implantation, and the requirement of revision surgeries. Various surgical approaches have been adopted by the surgeons to insert the spinal implants into the affected segment. Over the years, extensive biomechanical investigations have been reported on various surgical approaches and prostheses to predict the outcomes of lumbar spine implantations. Computer models have been proven to be very effective in identifying the best prosthesis and surgical procedure. The objective of the study was to review the literature on biomechanical studies for the treatment of lumbar spinal degenerative diseases. A critical review of the clinical and biomechanical studies on fusion spine surgeries was undertaken. The important modeling parameters, challenges, and limitations of the current studies were identified, showing the future research directions.
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Schlesinger SM, Gelber BR, Gerber MB, Lorio MP, Block JE. Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 1: Multi-Center Assessment of Surgical Safety. J Pers Med 2023; 13:jpm13020311. [PMID: 36836545 PMCID: PMC9962815 DOI: 10.3390/jpm13020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/04/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
(1) Background: The technological advances achieved with minimally-invasive surgery have enabled procedures to be undertaken in outpatient settings, and there has been growing acceptance of performing minimally-invasive transforaminal interbody fusion (TLIF) in the ambulatory surgery center (ASC). The purposeof this study was to determine the comparative 30 day safety profile for patients treated with TLIF in the ASC versus the hospital setting. (2) Methods: This multi-center study retrospectively collected baseline characteristics, perioperative variables, and 30 day postoperative safety outcomes for patients having a TLIF using the VariLift®-LX expandable lumbar interbody fusion device. Outcomes were compared between patients undergoing TLIF in the ASC (n = 53) versus in the hospital (n = 114). (3) Results: Patients treated in-hospital were significantly older, frailer and more likely to have had previous spinal surgery than ASC patients. Preoperative back and leg pain scores were similar between study groups (median, 7). ASC patients had almost exclusively one-level procedures (98%) vs. 20% of hospital procedures involving two-levels (p = 0.004). Most procedures (>90%) employed a stand-alone device. The median length of stay for hospital patients was five times greater than for ASC patients (1.4 days vs. 0.3 days, p = 0.001). Emergency department visits, re-admissions and reoperations were rare whether the patients were managed in the traditional hospital setting or the ASC. (4) Conclusions: There were equivalent 30 day postoperative safety profiles for patients undergoing a minimally-invasive TLIF irrespective of surgical setting. For appropriately selected surgical candidates, the ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.
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Affiliation(s)
- Scott M. Schlesinger
- Legacy Spine & Neurological Specialists, 8201 Cantrell Road, Ste. 265, Little Rock, AR 72227, USA
| | - Benjamin R. Gelber
- Neurological and Spinal Surgery, Bryan Medical Center West, 2222 S. 16th Street, Ste. 305, Tower B, Lincoln, NE 68502, USA
| | - Mark B. Gerber
- Neuroscience and Spine Associates, 6101 Pine Ridge Road, Ste. 101, Naples, FL 34119, USA
| | - Morgan P. Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Jon E. Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
- Correspondence: ; Tel.: +415-775-7947
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Canseco JA, Karamian BA, DiMaria SL, Patel PD, Divi SN, Chang M, Timmons T, Grewal L, Hallman H, Lee JK, Kaye ID, Woods BI, Kurd MF, Anderson DG, Rihn JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Static Versus Expandable Polyether Ether Ketone (PEEK) Interbody Cages: A Comparison of One-Year Clinical and Radiographic Outcomes for One-Level Transforaminal Lumbar Interbody Fusion. World Neurosurg 2021; 152:e492-e501. [PMID: 34098137 DOI: 10.1016/j.wneu.2021.05.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine the effect of static versus expandable polyether ether ketone (PEEK) cages on both clinical and radiographic outcomes. METHODS A retrospective cohort study was conducted on patients who underwent one-level transforaminal lumbar interbody fusion with either a static or expandable PEEK cage. Patient outcomes were obtained from chart review and radiographic outcomes were measured using standing, lateral radiographs. Recovery ratios and the proportion of patients achieving the minimally clinically important difference were calculated for Oswestry Disability Index (ODI), Physical Component Score-12, Mental Component Score-12, visual analogue scale for back, and visual analogue scale for leg at 1 year and compared between groups. Multivariate linear regression analysis was performed to determine the effect of cage type on the change in patient-reported outcome measures, controlling for demographic factors. RESULTS A total of 240 patients (137 static, 103 expandable) were included in the final analysis. ΔPhysical Component Score-12 scores at 3 months were significantly greater for the static group (16.0 vs. 10.0, P = 0.043) compared with the expandable group. Multivariate regression demonstrated that use of an expandable cage was associated with greater improvements in ΔODI (β: -7.82, P = 0.048) at 1 year. No differences were found in the perioperative change in sagittal spinal alignment within or between groups at 1 year. Subsidence rates failed to show any statistically significant difference between the 2 groups. CONCLUSIONS Transforaminal lumbar interbody fusion with an expandable PEEK cage is an independent predictor of improved ODI scores at 1 year. Our study showed no significant differences in subsidence rates or changes in sagittal spinal alignment between static and expandable PEEK cages.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Stephen L DiMaria
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parthik D Patel
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Srikanth N Divi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Chang
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tyler Timmons
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lovy Grewal
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haydn Hallman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph K Lee
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - D Greg Anderson
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Calvachi-Prieto P, McAvoy MB, Cerecedo-Lopez CD, Lu Y, Chi JH, Aglio LS, Smith TR, Gormley WB, Groff MW, Mekary RA, Zaidi HA. Expandable Versus Static Cages in Minimally Invasive Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 151:e607-e614. [PMID: 33940268 DOI: 10.1016/j.wneu.2021.04.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Expandable cages for interbody fusion allow for in situ expansion optimizing fit while mitigating endplate damage. Studies comparing outcomes after using expandable or static cages have been conflicting. METHODS This was a meta-analysis A systematic search was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines identifying studies reporting outcomes among patients who underwent minimally invasive lumbar interbody fusion (MIS-LIF). RESULTS Fourteen articles with 1129 patients met inclusion criteria. Compared with MIS-LIFs performed with static cages, those with expandable cages had a significantly lower incidence of graft subsidence (expandable: incidence 0.03, I2 22.50%; static: incidence 0.27, I2 51.03%, P interaction <0.001), length of hospital stay (expandable: mean difference [MD] 3.55 days, I2 97%; static: MD 7.1 days, I2 97%, P interaction <0.01), and a greater increase in disc height (expandable: MD -4.41 mm, I2 99.56%; static: MD -0.79 mm, I2 99.17%, P interaction = 0.02). There was no statistically significant difference among Oswestry Disability Index (expandable: MD -22.75, I2 98.17%; static: MD -17.11, I2 95.26%, P interaction = 0.15), fusion rate (expandable: incidence 0.94, I2 0%; static incidence 0.92, I2 0%, P interaction = 0.44), overall change in lumbar lordosis (expandable: MD 3.48 degrees, I2 59.29%; static: MD 3.67 degrees, I2 0.00%, P interaction 0.88), blood loss (expandable: MD 228.9 mL, I2 100%; static: MD 261.1 mL, I2 94%, P interaction = 0.69) and operative time (expandable: MD 184 minutes, I2 95.32%; static: MD 150.4 minutes, I2 91%, P interaction = 0.56). CONCLUSIONS Expandable interbody cages in MIS-LIF were associated with a decrease in subsidence rate, operative time and greater in increase in disc height.
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Affiliation(s)
- Paola Calvachi-Prieto
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Malia B McAvoy
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, University of Washington, Seattle, Washington, USA.
| | - Christian D Cerecedo-Lopez
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Lu
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
| | - John H Chi
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
| | - Linda S Aglio
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
| | - William B Gormley
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
| | - Michael W Groff
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
| | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts, USA
| | - Hasan A Zaidi
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Massachusetts, USA
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Stand-Alone Posterior Expandable Cage Technique for Adjacent Segment Degeneration with Lumbar Spinal Canal Stenosis: A Retrospective Case Series. ACTA ACUST UNITED AC 2021; 57:medicina57030237. [PMID: 33806505 PMCID: PMC8001591 DOI: 10.3390/medicina57030237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/21/2022]
Abstract
Background and Objectives: Symptomatic adjacent segment degeneration (ASD) with lumbar spinal canal stenosis (LSCS) is a common complication after spinal intervention, particularly interbody fusion. Stand-alone posterior expandable cages enable interbody fusion with preservation of the previous operation site, and screw-related complications are avoided. Thus, the aim of this study was to investigate the clinicoradiologic outcomes of stand-alone posterior expandable cages for ASD with LSCS. Materials and Methods: Patients with persistent neurologic symptoms and radiologically confirmed ASD with LSCS were evaluated between January 2011 and December 2016. The five-year follow-up data were used to evaluate the long-term outcomes. The radiologic parameters for sagittal balance, pain control (visual analogue scale), disability (Oswestry Disability Index), and early (peri-operative) and late (implant) complications were evaluated. Results: The data of 19 patients with stand-alone posterior expandable cages were evaluated. Local factors, such as intervertebral and foraminal heights, were significantly corrected (p < 0.01 and p < 0.01, respectively), and revision was not reported. The pain level (p < 0.01) and disability rate (p < 0.01) significantly improved, and the early complication rate was low (n = 2, 10.52%). However, lumbar lordosis (p = 0.62) and sagittal balance (p = 0.80) did not significantly improve. Furthermore, the rates of subsidence (n = 4, 21.05%) and retropulsion (n = 3, 15.79%) were high. Conclusions: A stand-alone expandable cage technique should only be considered for older adults and patients with previous extensive fusion. Although this technique is less invasive, improves the local radiologic factors, and yields favorable clinical outcomes with low revision rates, it does not improve the sagittal balance. For more widespread application, the strength of the cage material and high subsidence rates should be improved.
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Kim C, Cohen DS, Smith MD, Dix GA, Luna IY, Joshua G. Two-Year Clinical and Radiographic Outcomes of Expandable Interbody Spacers Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Study. Int J Spine Surg 2020; 14:518-526. [PMID: 32986572 DOI: 10.14444/7068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The advantages of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF) are well documented and include decreased blood loss, shorter length of hospital stay, and reduced perioperative costs. Clinical evidence for the use of expandable interbody spacers in conjunction with MIS TLIF, however, is scarce. This study sought to examine the clinical and radiographic outcomes of patients undergoing MIS TLIF with an expandable spacer. METHODS Forty patients from 4 institutions who underwent MIS TLIF with an expandable spacer were included in this study and followed for 24 months. Investigator assessment of the surgical technique was reported. Patient self-reported outcomes included Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form 36 (SF-36) physical and mental component scores. Disc height, foraminal height, segmental and lumbar lordosis, and fusion were also assessed. RESULTS Investigators reported that intraoperative insertion, impaction, number of passes through the neural structures, and fit were better with an expandable spacer than a static spacer. Significant improvements in VAS, ODI, and SF-36 were reported as early as 6 weeks postoperatively and maintained through 24 months. Mean intervertebral and foraminal heights improved significantly from the preoperative time interval to as early as 6 weeks postoperatively and maintained through 24 months. There were no cases of spacer migration, subsidence, or collapse. CONCLUSIONS The use of an expandable interbody spacer in combination with MIS TLIF resulted in positive investigator assessments, immediate and progressive symptom relief, significant radiographic improvements, and no spacer-related complications.
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Affiliation(s)
- Choll Kim
- Globus Medical Inc, Audubon, Pennsylvania
| | | | | | - Gary A Dix
- Globus Medical Inc, Audubon, Pennsylvania
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Kim SK, Elbashier OM, Lee SC, Choi WJ. Can posterior stand-alone expandable cages safely restore lumbar lordosis? A minimum 5-year follow-up study. J Orthop Surg Res 2020; 15:442. [PMID: 32993711 PMCID: PMC7523357 DOI: 10.1186/s13018-020-01866-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lumbar lordosis (LL) can be restored, and screw-related complications may be avoided with the stand-alone expandable cage method. However, the long-term spinopelvic changes and safety remain unknown. We aimed to elucidate the long-term radiologic outcomes and safety of this technique. METHODS Data from patients who underwent multi-level stand-alone expandable cage fusion and 80 patients who underwent screw-assisted fusion between February 2007 and December 2012, with at least 5 years of follow-up, were retrospectively analyzed. Segmental angle and translation, short and whole LL, pelvic incidence, pelvic tilt, sacral slope (SS), sagittal vertical axis, thoracic kyphosis, and presence of subsidence, pseudoarthrosis, retropulsion, cage breakage, proximal junctional kyphosis (PJK), and screw malposition were assessed. The relationship between local, lumbar, and spinopelvic effects was investigated. The implant failure rate was considered a measure of procedure effectiveness and safety. RESULTS In total, 69 cases were included in the stand-alone expandable cage group and 150 cases in the control group. The stand-alone group showed shorter operative time (58.48 ± 11.10 vs 81.43 ± 13.75, P = .00028), lower rate of PJK (10.1% vs 22.5%, P = .03), and restoration of local angle (4.66 ± 3.76 vs 2.03 ± 1.16, P = .000079) than the control group. However, sagittal balance (0.01 ± 2.57 vs 0.50 ± 2.10, P = .07) was not restored, and weakness showed higher rate of subsidence (16.31% vs 4.85%, P = .0018), pseudoarthrosis (9.92% vs 2.42%, P = .02), cage, and retropulsion (3.55% vs 0, P = .01) than the control group. CONCLUSIONS Stand-alone expandable cage fusion can restore local lordosis; however, global sagittal balance was not restored. Furthermore, implant safety has not yet been proven.
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Affiliation(s)
- Seung-Kook Kim
- Himchan and UHS Spine and Joint Centre, University Hospital Sharjah, Sharjah, United Arab Emirates.,Department of Pharmaceutical Medicine and Regulatory Sciences, College of Medicine and Pharmacy, Yonsei University, Seoul, Republic of South Korea.,Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Republic of South Korea
| | - Ogeil Mubarak Elbashier
- Himchan and UHS Spine and Joint Centre, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Su-Chan Lee
- Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Republic of South Korea
| | - Woo-Jin Choi
- Department of Spine Center, Neurosurgery, Hurisarang Hospital, 618 Gyeryong-ro, Seo-gu, Daejeon, 35299, Republic of South Korea.
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10
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Schlesinger S, Krugman K, Abbott D, Arle J. Thirty-Day Outcomes From Standalone Minimally Invasive Surgery-Transforaminal Lumbar Interbody Fusion Patients in an Ambulatory Surgery Center vs. Hospital Setting. Cureus 2020; 12:e10197. [PMID: 33033675 PMCID: PMC7532869 DOI: 10.7759/cureus.10197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives We sought to evaluate differences in perioperative baseline characteristics, operative efficiency, and 30-day safety events for patients undergoing standalone minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) in a hospital versus an ambulatory surgery center (ASC). Methods Patients were retrospectively identified and sequentially enrolled from the office records of a single, community neurosurgeon. Records for the first 50 qualifying patients in the hospital and ASC cohorts were retrieved. Variables collected included: baseline demographic and health status, operative safety (intra-op complications) and efficiency (operative time, fluoroscopy time, etc.), and 30-day post-operative safety (emergency room visits, re-admission, and re-operation). Results At baseline, hospital and ASC patients were equivalent in gender distribution, BMI, and pre-operative narcotic use. Statistically significant differences were found in age and comorbidity burden (ASA status and Charleson Comorbidity Index); p < 0.0001, p = 0.0039, and p < 0.001 respectively. The only significant difference in construct type between hospital and ASC patients was the proportion of one- versus two-level fusions; all two-level fusions were performed in the hospital group. There were no differences in operative time, need for transfusions, or iatrogenic complications. There were also no differences between the groups in 30-day events of ER visits, re-admission, re-operation, or post-operative narcotic refill use. The length of stay was significantly different between the ASC and hospital settings (p < 0.0001). Conclusions As expected, ASC patients were younger and relatively healthier compared to their hospital counterparts. Thirty-day safety events of ER visits, re-admission, re-operation, and narcotic refill utilization were representative of population norms. Patients with standalone, expandable MIS-TLIF underwent efficient operative procedures and experienced minimal 30-day complications independent of their operative status. ASC patients had the added benefit of significantly reduced length of stay over their hospital counterparts. Given the equivalency of the 30-day post-operative course for both patient cohorts, a substantial reduction in economic burden is likely for the ASC patients.
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Affiliation(s)
- Scott Schlesinger
- Neurosurgery, Legacy Spine and Neurological Specialists and Legacy Surgery Center, Little Rock, USA
| | | | - Diana Abbott
- Department of Biostatistics and Informatics, University of Colorado-Anschutz, Denver, USA
| | - Jeffrey Arle
- Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Maragkos GA, Motiei-Langroudi R, Arle J. Safety and Efficacy of the VariLift-C® Cervical Standalone Interbody Fusion Device with Emphasis on Multiple-level and Prior Fusion Cases. Cureus 2019; 11:e5885. [PMID: 31772855 PMCID: PMC6837266 DOI: 10.7759/cureus.5885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction The VariLift-C® is a stand-alone, expandable, cervical interbody fusion device, not requiring the addition of anterior plating. Because of the access and placement technique, as well as not needing a plate, the device could potentially be used preferentially for patients with prior anterior fusions or for multiple, non-contiguous vertebral segments. Methods A retrospective chart review was conducted and all cases of anterior cervical discectomy and fusion (ACDF) using VariLift-C® implants by a single surgeon were included. Patient baseline and operative characteristics were collected, and their follow-up notes were searched for outcomes. Descriptive statistics are provided. Results Seventy-one patients were included in this study, 14 of which had had a prior fusion, and 32 underwent a multilevel ACDF. A total of 108 cervical levels were fused. Mean age (± SD) at surgery was 50.3 ± 11.4 years and mean (± SD) follow-up was 6.5 ± 10.7 months. There were 39 single-level, 27 two-level and five three-level fusions. Four cases (5.6%) underwent multilevel re-operations. Thirty-three patients (80.3%) reported substantial improvement in their symptoms on follow-up, 19 of whom (26.8%) had no residual symptoms. Only two patients (2.8%) reported a worsened condition after surgery. There were 10 cases (12.8%) of postoperative neurologic deficit, one case of dysphagia and three cases of vocal cord paresis. Conclusions These results display the use of VariLift-C® for symptomatic cervical degenerative disorders, with a focus on fusion extension or multiple-segment ACDF procedures. Our experience with favorable self-reported outcomes and low complication rates showcases the safety and efficacy of the VariLift-C® device for ACDF.
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Affiliation(s)
| | | | - Jeffrey Arle
- Neurosurgery, Beth Israel Deaconess Medical Center
- Harvard Medical School, Boston, USA
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Is there any advantage of using stand-alone cages? A numerical approach. Biomed Eng Online 2019; 18:63. [PMID: 31113423 PMCID: PMC6530002 DOI: 10.1186/s12938-019-0684-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/14/2019] [Indexed: 11/17/2022] Open
Abstract
Background Segment fusion using interbody cages supplemented with pedicle screw fixation is the most common surgery for the treatment of low back pain. However, there is still much controversy regarding the use of cages in a stand-alone fashion. The goal of this work is to numerically compare the influence that each surgery has on lumbar biomechanics. Methods A non-linear FE model of the whole lumbar spine was developed to compare between two types of cages (OLYS and NEOLIF) with and without supplementary fixation. The motion of the whole spine was analysed and the biomechanical environment of the adjacent segments to the operated one was studied. Moreover, the risk of subsidence of the cages was qualitatively evaluated. Results A great ROM reduction occurred when supplementary fixation was used. This stiffening increased the stresses at the adjacent levels. It might be hypothesised that the overloading of these segments could be related with the clinically observed adjacent disc degeneration. Meanwhile, the stand-alone cages allowed for a wider movement, and therefore, the influence of the surgery on adjacent discs was much lower. Regarding the risk of subsidence, the contact pressure magnitude was similar for both intervertebral cage designs and near the value of the maximum tolerable pressure of the endplates. Conclusions A minimally invasive posterior insertion of an intervertebral cage (OLYS or NEOLIF) was compared using a stand-alone design or adding supplementary fixation. The outcomes of these two techniques were compared, and although stand-alone cage may diminish the risk of disease progression to the adjacent discs, the spinal movement in this case could compromise the vertebral fusion and might present a higher risk of cage subsidence.![]() Electronic supplementary material The online version of this article (10.1186/s12938-019-0684-8) contains supplementary material, which is available to authorized users.
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Gussous YM, Jain N, Khan SN. Posterior Based Lumbar Interbody Fusion Devices: Static and Expandable Technology. ACTA ACUST UNITED AC 2018. [DOI: 10.1053/j.semss.2018.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Zhang J, Pan A, Zhou L, Yu J, Zhang X. Comparison of unilateral pedicle screw fixation and interbody fusion with PEEK cage vs. standalone expandable fusion cage for the treatment of unilateral lumbar disc herniation. Arch Med Sci 2018; 14:1432-1438. [PMID: 30393499 PMCID: PMC6209698 DOI: 10.5114/aoms.2018.74890] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/17/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION This study was conducted to compare the clinical effects of unilateral pedicle screw fixation and interbody fusion with PEEK cage (UPSFC) and standalone expandable fusion cage (SAEFC) on unilateral lumbar disc herniation. MATERIAL AND METHODS From September 2011 to July 2014, a respective investigation was performed on 130 lumbar disc herniation patients treated with SAEFC or UPSFC. The hospital stay, operating time, blood loss, Japanese orthopaedic association scores (JOA), and visual analogue score (VAS) in the two groups were compared using Student's t-test. RESULTS The average of follow-up time was 25.6 ±6.4 and 25.2 ±5.8 months, respectively. No significant difference in the postoperative hospitalizsation, intraoperative blood loss, operative time, and postoperative fusion rate was detected between the two groups. VAS score in the UPSFC group was significantly lower than in the SAEFC group at 6 and 12 months after operation (p = 0.014, p = 0.004). X-ray images indicated that the subsidence rate was 8.1% (5/62) in the SAEFC group, while no subsidence was detected in UPSFC group 12 month after operation. CONCLUSIONS Both SAEFC and UPSFC are effective techniques. UPSFC may be a better choice for patients with lumbar disc herniation and unilateral limb symptoms of nerve root in view of the advantages of better low back pain relief and low subsidence rate.
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Affiliation(s)
- Jinlei Zhang
- Department of Orthopaedics, Zhoukou City Central Hospital, The Affiliated Hospital of Xinxiang Medical College, Zhoukou Shi, China
| | - Aixing Pan
- Department of Orthopaedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li Zhou
- Department of Orthopaedics, Zhoukou City Central Hospital, The Affiliated Hospital of Xinxiang Medical College, Zhoukou Shi, China
| | - Jingyi Yu
- Department of Orthopaedics, Zhoukou City Central Hospital, The Affiliated Hospital of Xinxiang Medical College, Zhoukou Shi, China
| | - Xiao Zhang
- Department of Orthopaedics, Zhoukou City Central Hospital, The Affiliated Hospital of Xinxiang Medical College, Zhoukou Shi, China
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Hawasli AH, Khalifeh JM, Chatrath A, Yarbrough CK, Ray WZ. Minimally invasive transforaminal lumbar interbody fusion with expandable versus static interbody devices: radiographic assessment of sagittal segmental and pelvic parameters. Neurosurg Focus 2018; 43:E10. [PMID: 28760032 DOI: 10.3171/2017.5.focus17197] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been adopted as an alternative technique to hasten recovery and minimize postoperative morbidity. Advances in instrumentation technologies and operative techniques have evolved to maximize patient outcomes as well as radiographic results. The development of expandable interbody devices allows a surgeon to perform MIS-TLIF with minimal tissue disruption. However, sagittal segmental and pelvic radiographic outcomes after MIS-TLIF with expandable interbody devices are not well characterized. The object of this study is to evaluate the radiographic sagittal lumbar segmental and pelvic parameter outcomes of MIS-TLIF performed using an expandable interbody device. METHODS A retrospective review of MIS-TLIFs performed between 2014 and 2016 at a high-volume center was performed. Radiographic measurements were performed on lateral radiographs before and after MIS-TLIF with static or expandable interbody devices. Radiographic measurements included disc height, foraminal height, fused disc angle, lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt. Mismatch between pelvic incidence and lumbar lordosis were calculated for each radiograph. RESULTS A total of 48 MIS-TLIFs were performed, predominantly at the L4-5 level, in 44 patients. MIS-TLIF with an expandable interbody device led to a greater and more sustained increase in disc height when compared with static interbody devices. Foraminal height increased after MIS-TLIF with expandable but not with static interbody devices. MIS-TLIF with expandable interbody devices increased index-level segmental lordosis more than with static interbody devices. The increase in segmental lordosis was sustained in the patients with expandable interbody devices but not in patients with static interbody devices. For patients with a collapsed disc space, MIS-TLIF with an expandable interbody device provided superior and longer-lasting increases in disc height, foraminal height, and index-level segmental lordosis than in comparison with patients with static interbody devices. Using an expandable interbody device improved the Oswestry Disability Index scores more than using a static interbody device, and both disc height and segmental lordosis were correlated with improved clinical outcome. Lumbar MIS-TLIF with expandable or static interbody devices had no effect on overall lumbar lordosis, pelvic parameters, or pelvic incidence-lumbar lordosis mismatch. CONCLUSIONS Performing MIS-TLIF with an expandable interbody device led to a greater and longer-lasting restoration of disc height, foraminal height, and index-level segmental lordosis than MIS-TLIF with a static interbody device, especially for patients with a collapsed disc space. However, neither technique had any effect on radiographic pelvic parameters.
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Affiliation(s)
- Ammar H Hawasli
- Departments of 1 Neurological Surgery and.,Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri; and
| | | | | | - Chester K Yarbrough
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
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Barrett-Tuck R, Del Monaco D, Block JE. One and two level posterior lumbar interbody fusion (PLIF) using an expandable, stand-alone, interbody fusion device: a VariLift ® case series. JOURNAL OF SPINE SURGERY 2017; 3:9-15. [PMID: 28435912 DOI: 10.21037/jss.2017.02.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgical interventions such as posterior lumbar interbody fusion (PLIF) with and without posterior instrumentation are often employed in patients with degenerative spinal conditions that fail to respond to conservative medical management. The VariLift® Interbody Fusion System was developed as a stand-alone solution to provide the benefits of an intervertebral fusion device without the requirement of supplemental pedicle screw fixation. METHODS In this retrospective case series, 25 patients underwent PLIF with a stand-alone VariLift® expandable interbody fusion device without adjunctive pedicle screw fixation. There were 12 men and 13 women, with a mean age of 57.2 years (range, 33-83 years); single level in 18 patients, 2 levels in 7 patients. Back pain severity was reported as none, mild, moderate, severe and worst imaginable at baseline, 6 and 12 months. Preoperatively, 88% (22 of 25) of patients reported severe back pain. RESULTS All patients experienced symptomatic improvement and, by 12 months postoperatively, 71% (15 of 21) of patients reported only mild residual pain. Overall, pain scores improved significantly from baseline to 12 months (P=0.0002). There were no revision surgeries and fusion was achieved 12 of 13 patients (92%) who returned for a 12-month radiographic follow-up. There were three cases of intractable postsurgical pain which required extended hospitalization or pain management, one wound infection and one case of surgical site dehiscence, both treated and resolved during inpatient hospitalization. CONCLUSIONS In this single-physician case series, the VariLift® device used in single or two-level PLIF provided effective symptom relief and produced a high fusion rate without the need for supplemental fixation.
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Affiliation(s)
| | - Diana Del Monaco
- Wenzel Spine, Inc., 1130 Rutherford Lane, Ste. 200, Austin, TX 78753, USA
| | - Jon E Block
- 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
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