Risk factors for cage retropulsion after transforaminal lumbar interbody fusion in older patients

A meta-analysis of risk factors for cage migration after lumbar fusion surgery

Objective

Cage migration is a rare complication after lumbar fusion surgery, and it is also the cause of lumbar revision surgery. Previous studies have reported that many influencing factors can increase the incidence of cage migration. However, there still remains controversial. The current study was conducted to investigate the risk factors influencing incidence of cage migration.

Methods

A systematic database search of PubMed, Embase, Web of Science, Cochrane Library and Clinical Trials was performed for relevant articles published until July 2022. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction and quality evaluation of the obtained literature. The Newcastle-Ottawa Scale (NOS) score was used for quality evaluation, and meta-analysis was performed by STATA 16.0 software.

Results

A total of 2126 relevant articles were initially identified, and 7 articles were finally included in this study for data extraction and meta-analysis. The results of meta-analysis showed that the bony endplate injury, pear-shaped disc, and screw loosening are significantly correlated with cage migration. The OR values (95%CI) of the three factors were 7.170 (3.015, 17.051), 8.056 (4.050, 16.023), and 12.840 (3.570, 46.177) respectively.

Conclusion

Bony endplate injury, pear-shaped disc, and screw loosening are the current risk factors for cage migration postoperatively.

Revision for cage migration after transforaminal/posterior lumbar interbody fusion: how to perform revision surgery?

Background

Symptomatic pseudarthrosis and cage migration/protrusion are difficult complications of transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). If the patient experiences severe radicular symptoms due to cage protrusion, removal of the migrated cage is necessary. However, this procedure is sometimes very challenging because epidural adhesions and fibrous union can be present between the cage and vertebrae. We describe a novel classification and technique utilizing a navigated osteotome and the oblique lumbar interbody fusion at L5/S1 (OLIF51) technique to address this problem.

Methods

This retrospective study investigated consecutive patients with degenerative lumbar diseases who underwent TLIF/PLIF. Symptomatic cage migration was evaluated by direct examination, radiography, and/or computed tomography (CT) at 1, 3, 6, 12, and 24 months of follow-up. Cage migration/protrusion was defined as symptomatic cage protrusion > 5 mm from the posterior border of the over and underlying vertebral body compared with initial CT. We evaluated patient characteristics including body mass index, smoking history, fusion level, and cage type. A total of 113 patients underwent PLIF/TLIF (PLIF n = 30, TLIF n = 83), with a mean age of 71.1 years (range, 28–87 years). Mean duration of follow-up was 25 months (range, 12–47 months).

Results

Cage migration was identified in 5 of 113 patients (4.4%). All cases of symptomatic cage migration involved the L5/S1 level and the TLIF procedure. Risk factors for cage protrusion were age (younger), sex (male), and level (L5/S1). The mean duration to onset of cage protrusion was 3.2 months (range, 2–6 months). We applied a new classification for cage protrusion: type 1, only low back pain without new radicular symptoms; type 2, low back pain with minor radicular symptoms; or type 3, cauda equina syndrome and/or severe radicular symptoms. According to our classification, one patient was in type 1, three patients were in type 2, and one patient was in type 3. For all cases of cage migration, revision surgery was performed using a navigated high-speed burr and osteotome, and the patient in group 1 underwent additional PLIF without removal of the protruding cage. Three revision surgeries (group 2) involved removal of the protruding cage and PLIF, and one revision surgery (group 3) involved anterior removal of the cage and OLIF51 fusion.

Conclusions

The navigated high-speed burr, navigated osteotome, and OLIF51 technique appear very useful for removing a cage with fibrous union from the disc in patients with pseudarthrosis. This new technique makes revision surgery after cage migration much safer, and more effective. This technique also reduces the need for fluoroscopy.

Comparison of Long-Term Efficacy of MIS-TLIF Intraoperative Implants in Patients with Osteoporosis

Osteoporosis and degenerative spinal disease are still an unsolvable surgical problem. It is still difficult to solve the complications related to postoperative osteoporosis, such as cage subsidence, displacement, and retraction. Expandable interbody cage is a recent innovation and an increasingly popular alternative to standard static cage. However, the clinical efficacy of MIS-TLIF combined with expandable cage for the treatment of osteoporosis has limited reports. The purpose of this paper was to analyze the efficacy of MIS-TLIF with expandable cage in patients with degenerative lumbar disease with osteoporosis. Patients with osteoporosis who received single-level MIS-TLIF and were followed up for at least 1 year were included. The outcome measures are as follows: clinical features, perioperative period, and neurological complications. JOA score and VAS pain score were used to analyze the improvement of patients’ function. Imaging analysis included segmental lordosis (SL), lumbar lordosis (LL), intervertebral disc height (DH), and the ratio of cage height to preoperative DH (RCD). The final data analysis included 284 patients with osteoporosis. 178 patients used static cages, and 106 patients used expandable cages. There was no significant difference in baseline characteristics, surgical indexes, and JOA and VAS scores between the two groups. There was no difference in SL or LL between static group and expandable group. There was no significant difference in preoperative DH between the two groups. The RCD in the expansion group was significantly lower than that in the static group. The intraoperative and postoperative sedimentation rate in the static group was significantly higher than that in the expandable group. The use of expandable cages in MIS-TLIF has shown good results for the treatment of degenerative lumbar diseases with osteoporosis. Through appropriate surgical techniques, the expandable cage can reduce the risk of cage sinking.

Concurrent Treatment with Vitamin K2 and D3 on Spine Fusion in Patients with Osteoporosis-Associated Lumbar Degenerative Disorders

STUDY DESIGN

A prospective and nonrandomized concurrent controlled trial.

OBJECTIVE

To address the early effects of concurrent treatment with vitamin K2 and vitamin D3 on fusion rates in patients who have undergone spinal surgery.

SUMMARY OF BACKGROUND DATA

Intervertebral pseudarthrosis has been reported after transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF), especially in patients with osteopenia or osteoporosis. No study has assessed the early effects of concurrent treatment with vitamin K2 and vitamin D3 on fusion rates.

METHODS

Patients with osteopenia or osteoporosis who underwent TLIF or PLIF in our department were included. Patients in the VK2+VD3 group received vitamin K2, vitamin D3, and calcium treatment, whereas subjects in the control group only received calcium and vitamin D3. Spine fusion was evaluated by computed tomography. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and visual analog scale (VAS) were used to assess the clinical and neurological symptoms. Bone mineral density (BMD) and bone metabolism markers were measured for osteoporotic evaluation.

RESULTS

Seventy-eight patients were included, and nine patients subsequently discontinued because of 2019-nCoV. At six months postoperatively, complete fusion rates were significantly higher in the VK2+VD3 group than that in the control group (91.18% vs 71.43%, P = 0.036). At six months postoperatively, BMD was increased in the VK2+VD3 group and was higher than that in the control group, although there was no significant difference. At three months postoperatively, a significant increase in procollagen type I amino terminal propeptide (91.81%) and a slight decrease in C-terminal end peptide (8.06%) were observed in the VK2+VD3 group. In both groups, the JOA-BPEQ and VAS scores were significantly improved after spine surgery.

CONCLUSION

Administration of vitamin K2 and vitamin D3 can increase lumbar interbody fusion rates, improve clinical symptoms, promote bone information, and avoid further decline in BMD within six months after TLIF or PLIF.Level of Evidence: 3.