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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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Kumar RP, Elsayed GA, Hafez DM, Agarwal N. Advances in Anterolateral Approaches to the Lumbar Spine: A Focus on Technological Developments. Neurosurg Clin N Am 2024; 35:199-205. [PMID: 38423735 DOI: 10.1016/j.nec.2023.11.006] [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: 03/02/2024]
Abstract
A historical overview of the evolution of anterolateral approaches to the lumber spine and associated patient outcomes is presented. In addition, the modern incorporation of new technologies is discussed, including interbody cages, intraoperative image guidance, robotics, augmented reality, and machine learning, which have significantly improved the spine surgery safety and efficacy profile. Current challenges and future directions are also covered, emphasizing the need for further research and development, particularly in robotic assistance and machine learning algorithms.
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Affiliation(s)
- Rohit Prem Kumar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Galal A Elsayed
- Och Spine, Weill Cornell Medicine/NewYork-Presbyterian, 525 East 68th Street, New York, NY 10068, USA
| | - Daniel M Hafez
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8057, St. Louis, Missouri 63110, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Song Z, Zhang Z, Zheng J, Zhang K, Wang F, Ran M, Luo J. Short-term and mid-term evaluation of three types of minimally invasive lumbar fusion surgery for treatment of L4/L5 degenerative spondylolisthesis. Sci Rep 2024; 14:4320. [PMID: 38383595 PMCID: PMC10881486 DOI: 10.1038/s41598-024-54970-5] [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: 07/15/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024] Open
Abstract
This was a single-centre retrospective study. Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF), oblique lumbar interbody fusion (OLIF), and percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) have been extensively used for lumbar degenerative diseases. The present study analyses the short-term and mid-term clinical effects of the above three minimally invasive techniques on L4/L5 degenerative spondylolisthesis. In this retrospective study, 98 patients with L4/L5 degenerative spondylolisthesis received MIS-TLIF, 107 received OLIF, and 114 received Endo-TLIF. All patients were followed up for at least one year. We compared patient data, including age, sex, body mass index (BMI), Oswestry disability index (ODI), visual analogue scale of low back pain (VAS-B), visual analogue scale of leg pain (VAS-L), surgical time, blood loss, drainage volume, hospital stay, complications, and neurological status. Moreover, we performed imaging evaluations, including lumbar lordosis angle (LLA), disc height (DH) and intervertebral fusion status. No significant differences were noted in age, sex, BMI, preoperative ODI, preoperative VAS-B, preoperative VAS-L, preoperative LLA, or preoperative DH. Patients who underwent OLIF had significantly decreased blood loss, a lower drainage volume, and a shorter hospital stay than those who underwent MIS-TLIF or Endo-TLIF (P < 0.05). The VAS-B in the OLIF group significantly decreased compared with in the MIS-TLIF and Endo-TLIF groups at 6 and 12 months postoperatively (P < 0.05). The VAS-L in the Endo-TLIF group significantly decreased compared with that in the MIS-TLIF and OLIF groups at 6 months postoperatively (P < 0.05). The ODI in the OLIF group was significantly better than that in the MIS-TLIF and Endo-TLIF groups at 6 months postoperatively (P < 0.05). No statistically significant differences in the incidence of complications and healthcare cost were found among the three groups. Follow-up LLA and DH changes were significantly lower in the OLIF group than in the other groups (P < 0.05). The intervertebral fusion rate was significantly higher in the OLIF group than in the other groups at 6 and 12 months postoperatively (P < 0.05). In conclusion, while MIS-TLIF, OLIF, and Endo-TLIF techniques can effectively treat patients with L4/5 degenerative spondylolisthesis, OLIF has more benefits, including less operative blood loss, a shorter hospital stay, a smaller drainage volume, efficacy for back pain, effective maintenance of lumbar lordosis angle and disc height, and a higher fusion rate. OLIF should be the preferred surgical treatment for patients with L4/5 degenerative spondylolisthesis.
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Affiliation(s)
- Zhaojun Song
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Zhi Zhang
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Jiazhuang Zheng
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Kai Zhang
- Operation Room of Suining Central Hospital, Sichuan, People's Republic of China
| | - Fandong Wang
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Maobo Ran
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Juan Luo
- Medical Record Department of Suining Central Hospital, Sichuan, People's Republic of China.
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Bekas KN, Zafeiris C. The Role of Bone Mineral Density in a Successful Lumbar Interbody Fusion: A Narrative Review. Cureus 2024; 16:e54727. [PMID: 38524011 PMCID: PMC10960932 DOI: 10.7759/cureus.54727] [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] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The incidence of osteoporosis is a prime concern, especially in parts of the world where the population is aging, such as Europe or the US. Many new therapy strategies have been described to enhance bone healing. Lumbar interbody fusion (LIF) is a surgical procedure that aims to stabilize the lumbar spine by fusing two or more vertebrae using an interbody cage. LIF is a standard treatment for various spinal conditions, such as degenerative disc disease, spinal stenosis, and spondylolisthesis. However, successful fusion is challenging for patients with osteoporosis due to their reduced bone mineral density (BMD) and increased risk of cage subsidence, which can lead to implant failure and poor clinical outcomes. METHODS A comprehensive literature search yielded 220 articles, with 16 ultimately included. Keywords included BMD, cage subsidence, osteoporosis, teriparatide, and lumbar interbody fusion. RESULTS This review examines the relationship between BMD and LIF success, emphasizing the importance of adequate bone quality for successful fusion. Preoperative assessment methods for BMD and the impact of low BMD on fusion rates and patient outcomes are discussed. Additionally, techniques to improve fusion success in patients with weakened bone density, such as biological enhancement and BMD-matched interbody cages, are explored. However, consensus on the exact BMD threshold for a successful outcome remains elusive. CONCLUSION While an apparent correlation between BMD and fusion rate in LIF procedures is acknowledged, conclusive evidence regarding the precise BMD threshold indicative of an increased risk of unfavorable outcomes remains elusive. Surgeons are advised to exercise caution in surgical planning and follow-up for patients with lower BMD. Furthermore, future research initiatives, particularly longitudinal studies, are encouraged to prioritize the examination of BMD as a fundamental risk factor, addressing gaps in the literature.
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Affiliation(s)
- Kyriakos N Bekas
- Orthopaedics, 1st Orthopaedics Department, G. Gennimatas General Hospital, Athens, GRC
- Th. Garofalidis Laboratory for Research of the Musculoskeletal System, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Christos Zafeiris
- Th. Garofalidis Laboratory for Research of the Musculoskeletal System, Medical School, National and Kapodistrian University of Athens, Athens, GRC
- Orthopaedics and Spine Surgery, Metropolitan General Hospital, Athens, GRC
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Meyrat R, Vivian E, Sridhar A, Gulden RH, Bruce S, Martinez A, Montgomery L, Reed DN, Rappa PJ, Makanbhai H, Raney K, Belisle J, Castellanos S, Cwikla J, Elzey K, Wilck K, Nicolosi F, Sabat ME, Shoup C, Graham RB, Katzen S, Mitchell B, Oh MC, Patel N. Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review. Medicine (Baltimore) 2023; 102:e36142. [PMID: 38013300 PMCID: PMC10681460 DOI: 10.1097/md.0000000000036142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023] Open
Abstract
The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.
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Affiliation(s)
- Richard Meyrat
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Elaina Vivian
- Performance Improvement, Methodist Dallas Medical Center, Dallas, TX
| | - Archana Sridhar
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - R. Heath Gulden
- Anesthesia Consultants of Dallas Division, US Anesthesia Partners, Dallas, TX
| | - Sue Bruce
- Clinical Outcomes Management, Methodist Dallas Medical Center, Dallas, TX
| | - Amber Martinez
- Pre-Surgery Assessment, Methodist Dallas Medical Center, Dallas, TX
| | - Lisa Montgomery
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Donald N. Reed
- Neurosurgery Division, Methodist Health System, Dallas, TX
| | | | | | | | | | - Stacey Castellanos
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Judy Cwikla
- Neurocritical Care Unit, Methodist Dallas Medical Center, Dallas, TX
| | - Kristin Elzey
- Pharmacy, Methodist Dallas Medical Center, Dallas, TX
| | - Kristen Wilck
- Clinical Nutrition, Methodist Dallas Medical Center, Dallas, TX
| | - Fallon Nicolosi
- Methodist Community Pharmacy – Dallas, Methodist Dallas Medical Center, Dallas, TX
| | - Michael E. Sabat
- Surgery and Recovery, Methodist Dallas Medical Center, Dallas, TX
| | - Chris Shoup
- Executive Office, Methodist Health System, Dallas, TX
| | - Randall B. Graham
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Stephen Katzen
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Bartley Mitchell
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Michael C. Oh
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Nimesh Patel
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
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Toma AA, Hallager DW, Bech RD, Carreon LY, Andersen MØ, Udby PM. Stand-alone ALIF versus TLIF in patients with low back pain - A propensity-matched cohort study with two-year follow-up. BRAIN & SPINE 2023; 3:102713. [PMID: 38021018 PMCID: PMC10668097 DOI: 10.1016/j.bas.2023.102713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/05/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Instrumented lumbar fusion by either the anterior or transforaminal approach has different advantages and disadvantages. Few studies have compared PatientReported Outcomes Measures (PROMs) between stand-alone anterior lumbar interbody fusion (SA-ALIF) and transforaminal lumbar interbody fusion (TLIF). Research question This is a register-based dual-center study on patients with severe disc degeneration (DD) and low back pain (LBP) undergoing single-level SA-ALIF or TLIF. Comparing PROMs, including disability, quality of life, back- and leg-pain and patient satisfaction two years after SA-ALIF or TLIF, respectively. Material and methods Data were collected preoperatively and at one and two-year follow-up. The primary outcome was Oswestry Disability Index (ODI). The secondary outcomes were patient satisfaction, walking ability, visual analog scale (VAS) scores for back and leg pain, and quality of life (QoL) measured by the European Quality of Life-5 Dimensions (EQ-5D) index score. To reduce baseline differences between groups, propensity-score matching was employed in a 1:1 fashion. Results 92 patients were matched, 46 S A-ALIF and 46 TLIF. They were comparable preoperatively, with no significant difference in demographic data or PROMs (P > 0.10). Both groups obtained statistically significant improvement in the ODI, QoL and VAS-score (P < 0.01), but no significant difference was observed (P = 0.14). No statistically significant differences in EQ-5D index scores (P = 0.25), VAS score for leg pain (P = 0.88) and back pain (P = 0.37) at two years follow-up. Conclusion Significant improvements in ODI, VAS-scores for back and leg pain, and EQ-5D index score were registered after two-year follow-up with both SA-ALIF and TLIF. No significant differences in improvement.
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Affiliation(s)
- Ali A. Toma
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Koege, Denmark
| | - Dennis W. Hallager
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Koege, Denmark
| | - Rune D. Bech
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Koege, Denmark
| | - Leah Y. Carreon
- Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
| | - Mikkel Ø. Andersen
- Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
| | - Peter M. Udby
- Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Koege, Denmark
- Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark
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Nguyen AQ, Credille K, Saifi C. Short-term and Long-term Complications of Cervical Disc Arthroplasty. Clin Spine Surg 2023; 36:404-410. [PMID: 37752635 DOI: 10.1097/bsd.0000000000001541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/28/2023]
Abstract
STUDY DESIGN A narrative review. OBJECTIVE This review discusses the short and long-term complications associated with cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA CDA is a safe and effective motion-sparing alternative to fusion for the treatment of cervical disc pathology in patients with cervical radiculopathy or myelopathy. Although CDA offers advantages over fusion within a narrower set of indications, it introduces new technical challenges and potential complications. METHODS A systematic search of several large databases, including Cochrane Central, PubMed, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry, was conducted from January 2005 to August 2023 to identify published studies and clinical trials evaluating cervical disc replacement complications and outcomes. RESULTS Short-term complications are primarily related to surgical approach and include dysphagia reported as high as ~70%, laryngeal nerve injury ~0%-1.25%, Horner syndrome ~0.06%, hematoma ~0.01%, gross device extrusion ~0.3%, whereas long-term complications include adjacent segment disease reported at ~3.8%, osteolysis ~44%-64%, heterotopic ossification ~7.3%-69.2%, implant failure ~3.3%-3.7%, and implant wear, which varies depending on design. CONCLUSIONS Approaches for mitigating complications broadly include meticulous dissection, intraoperative techniques, and diligent postoperative follow-up. This review emphasizes the need for a comprehensive understanding and management of complications to enhance the safety, reproducibility, and success of CDA. As CDA continues to evolve, there remains a critical need for ongoing research to delve deeper into evaluating risk for complications and long-term patient outcomes.
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Affiliation(s)
- Austin Q Nguyen
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
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Rickert M, Fennema P, Wehner D, Rahim T, Hölper B, Eichler M, Makowski M, Meurer A, Brenneis M. Postoperative cage migration and subsidence following TLIF surgery is not associated with bony fusion. Sci Rep 2023; 13:12597. [PMID: 37537231 PMCID: PMC10400549 DOI: 10.1038/s41598-023-38801-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/14/2023] [Indexed: 08/05/2023] Open
Abstract
Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited.
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Affiliation(s)
- Marcus Rickert
- Spine Department, Schön Klinik Lorsch, Wilhelm Leuschner Strasse 10, Lorsch, Germany.
| | - Peter Fennema
- ARM Advanced Medical Research, Hofenstrasse 89b, 8708, Männedorf, Switzerland
| | - Diana Wehner
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Tamim Rahim
- Asklepios Klinik Wiesbaden GmbH, Geisenheimer Straße 10, 65197, Wiesbaden, Germany
| | - Bernd Hölper
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Michael Eichler
- Wirbelsäulenzentrum Fulda/Main/Kinzig, Hailerer Straße 16, 63571, Gelnhausen, Germany
| | - Marcus Makowski
- Department of Radiology, MRI TU Munich, Klinikum rechts der isar der TU München, Ismaninger Strasse 22, Munich, Germany
| | - Andrea Meurer
- Department of Orthopedics, Orthopadische Universitatsklinik Friedrichsheim gGmbH, Frankfurt am Main, Hessen, Germany
| | - Marco Brenneis
- Department of Trauma and Orthopaedic Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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9
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Kiapour A, Massaad E, Kodigudla MK, Kelkar A, Begley MR, Goel VK, Block JE, Shin JH. Resisting subsidence with a truss Implant: Application of the "Snowshoe" principle for interbody fusion devices. J Biomech 2023; 155:111635. [PMID: 37216894 DOI: 10.1016/j.jbiomech.2023.111635] [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: 11/03/2022] [Revised: 04/10/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023]
Abstract
The primary objective was to compare the subsidence resistance properties of a novel 3D-printed spinal interbody titanium implant versus a predicate polymeric annular cage. We evaluated a 3D-printed spinal interbody fusion device that employs truss-based bio-architectural features to apply the snowshoe principle of line length contact to provide efficient load distribution across the implant/endplate interface as means of resisting implant subsidence. Devices were tested mechanically using synthetic bone blocks of differing densities (osteoporotic to normal) to determine the corresponding resistance to subsidence under compressive load. Statistical analyses were performed to compare the subsidence loads and evaluate the effect of cage length on subsidence resistance. The truss implant demonstrated a marked rectilinear increase in resistance to subsidence associated with increase in the line length contact interface that corresponds with implant length irrespective of subsidence rate or bone density. In blocks simulating osteoporotic bone, comparing the shortest with the longest length truss cage (40 vs. 60 mm), the average compressive load necessary to induce subsidence of the implant increased by 46.4% (383.2 to 561.0 N) and 49.3% (567.4 to 847.2 N) for 1 and 2 mm of subsidence, respectively. In contrast, for annular cages, there was only a modest increase in compressive load when comparing the shortest with the longest length cage at a 1 mm subsidence rate. The Snowshoe truss cages demonstrated substantially more resistance to subsidence than corresponding annular cages. Clinical studies are required to support the biomechanical findings in this work.
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Affiliation(s)
- Ali Kiapour
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Elie Massaad
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Manoj K Kodigudla
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | - Amey Kelkar
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | - Matthew R Begley
- Department of Mechanical Engineering, University of California, Santa Barbara, CA, USA
| | - Vijay K Goel
- Engineering Center for Orthopedic Research Excellence, The University of Toledo, Toledo, OH, USA
| | | | - John H Shin
- Department of Neurosurgery Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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10
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You KH, Hwang JY, Hong SH, Kang MS, Park SM, Park HJ. Biportal endoscopic extraforaminal lumbar interbody fusion using a 3D-printed porous titanium cage with large footprints: technical note and preliminary results. Acta Neurochir (Wien) 2023; 165:1435-1443. [PMID: 37115323 DOI: 10.1007/s00701-023-05605-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE The aim of this study was to introduce biportal endoscopic extraforaminal lumbar interbody fusion (BE-EFLIF), which involves insertion of a cage through a more lateral side as compared to the conventional corridor of transforaminal lumbar interbody fusion. We described the advantages and surgical steps of 3D-printed porous titanium cage with large footprints insertion through multi-portal approach, and preliminary results of this technique. METHODS This retrospective study included 12 consecutive patients who underwent BE-EFLIF for symptomatic single-level lumbar degenerative disease. Clinical outcomes, including a visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI), were collected at preoperative months 1 and 3, and 6 months postoperatively. In addition, perioperative data and radiographic parameters were analyzed. RESULTS The mean patient age, follow-up period, operation time, and volume of surgical drainage were 68.3 ± 8.4 years, 7.6 ± 2.8 months, 188.3 ± 42.4 min, 92.5 ± 49.6 mL, respectively. There were no transfusion cases. All patients showed significant improvement in VAS and ODI postoperatively, and these were maintained for 6 months after surgery (P < 0.001). The anterior and posterior disc heights significantly increased after surgery (P < 0.001), and the cage was ideally positioned in all patients. There were no incidences of early cage subsidence or other complications. CONCLUSIONS BE-EFLIF using a 3D-printed porous titanium cage with large footprints is a feasible option for minimally invasive lumbar interbody fusion. This technique is expected to reduce the risk of cage subsidence and improve the fusion rate.
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Affiliation(s)
- Ki-Han You
- Department of Orthopedic Surgery, Spine Center, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Jae-Yeun Hwang
- Department of Orthopedic Surgery, Spine Center, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Seok-Ho Hong
- Department of Orthopedic Surgery, Spine Center, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Min-Seok Kang
- Department of Orthopedic Surgery, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Sang-Min Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hyun-Jin Park
- Department of Orthopedic Surgery, Spine Center, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea.
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Lefèvre E, Szadkowski M, Fière V, Vieira TD, Ould-Slimane M, d'Astorg H. Implications of cage impactions in single-level OLIF treatment of degenerative spondylolisthesis. Orthop Traumatol Surg Res 2023; 109:103385. [PMID: 35933020 DOI: 10.1016/j.otsr.2022.103385] [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] [Received: 05/28/2021] [Revised: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Cage impactions (CI) of Oblique Lumbar Interbody Fusion (OLIF) appear to be a frequent mechanical complication with a potential functional impact. OBJECTIVES To determine the rate of CI occurrence, their risk factors and clinical implications in the case of combined single-level arthrodesis. METHOD A retrospective analysis of prospectively collected data was performed. All our patients with degenerative spondylolisthesis initially underwent OLIF combined with pedicle screw fixation (PSF). Intraoperative control with an image intensifier and a standard radiograph in the immediate postoperative period made it possible to assess the occurrence of CI, depending on the position of the implant. Secondary subsidence was sought on the standing radiological examination using EOS biplanar radiography during follow-up. The pelvic parameters were analyzed, as well as the occurrence of bone fusion. The clinical evaluation was made at≥1 year, by the Oswestry Disability Index (ODI), the walking distance (WD) and the Visual Analogue Scale (VAS). RESULTS In all, 130 patients out of the 131 included were analyzed. A CI occurred in 25.3% (n=33) of cases and of these, 94% (n=32) occurred intraoperatively. Postmenopausal women had more CI with an odds ratio (OR) of 5.8 (P=0.034). The "CI" group had a 9.5% lower ODI score than the "non-CI" group (P=0.0040), but both provided excellent ODI gains of 30.8±16 and 32.9±15.5% (P<0.0001). An "anterior" position of the implant allowed a greater gain in lumbar lordosis (P<0.001) but was associated with greater CI occurrence (P<0.001), with an OR of 6.75 (P=0.0018). CONCLUSION The occurrence of intraoperative cage impaction is a frequent event when performing OLIF. Postmenopausal women have an approximately 6 times greater risk of impaction than men, and patients with an "anterior" implant placement have a 7 times greater risk than with central placement. The negative impact of cage impactions on the clinical score (ODI) was significant after one year of follow-up. LEVEL OF EVIDENCE IV, non-comparative cohort study.
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Affiliation(s)
- Emeric Lefèvre
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Marc Szadkowski
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Vincent Fière
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.
| | | | - Henri d'Astorg
- Centre orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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12
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Weng Y, Di M, Wu T, Ma X, Yang Q, Lu WW. Endplate volumetric bone mineral density biomechanically matched interbody cage. Front Bioeng Biotechnol 2022; 10:1075574. [PMID: 36561040 PMCID: PMC9763577 DOI: 10.3389/fbioe.2022.1075574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Disc degenerative problems affect the aging population, globally, and interbody fusion is a crucial surgical treatment. The interbody cage is the critical implant in interbody fusion surgery; however, its subsidence risk becomes a remarkable clinical complication. Cage subsidence is caused due to a mismatch of material properties between the bone and implant, specifically, the higher elastic modulus of the cage relative to that of the spinal segments, inducing subsidence. Our recent observation has demonstrated that endplate volumetric bone mineral density (EP-vBMD) measured through the greatest cortex-occupied 1.25-mm height region of interest, using automatic phantomless quantitative computed tomography scanning, could be an independent cage subsidence predictor and a tool for cage selection instruction. Porous design on the metallic cage is a trend in interbody fusion devices as it provides a solution to the subsidence problem. Moreover, the superior osseointegration effect of the metallic cage, like the titanium alloy cage, is retained. Patient-specific customization of porous metallic cages based on the greatest subsidence-related EP-vBMD may be a good modification for the cage design as it can achieve biomechanical matching with the contacting bone tissue. We proposed a novel perspective on porous metallic cages by customizing the elastic modulus of porous metallic cages by modifying its porosity according to endplate elastic modulus calculated from EP-vBMD. A three-grade porosity customization strategy was introduced, and direct porosity-modulus customization was also available depending on the patient's or doctor's discretion.
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Affiliation(s)
- Yuanzhi Weng
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Mingyuan Di
- Graduate School, Tianjin Medical University, Tianjin, China,Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Tianchi Wu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xinlong Ma
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
| | - Weijia William Lu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China,Research Center for Human Tissue and Organs Degeneration, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
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13
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Pu HY, Chen Q, Huang K, Zeng R, Wei P. Forearm T-score as a predictor of cage subsidence in patients with degenerative lumbar spine disease following posterior single-segment lumbar interbody fusion. BMC Musculoskelet Disord 2022; 23:1058. [PMID: 36471300 PMCID: PMC9721049 DOI: 10.1186/s12891-022-05930-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Posterior lumbar interbody fusion (PLIF) has become a classic treatment modality for lumbar degenerative diseases, with cage subsidence as a potentially fatal complication due to low bone mineral density (BMD), which can be measured by forearm T-score. Hounsfield units (HU) derived from computed tomography have been a reliable method for assessing BMD. OBJECTIVE To determine the accuracy of forearm T-score in predicting cage subsidence after PLIF compared with lumbar spine HU values. METHODS We retrospectively analyzed the clinical data of 71 patients who underwent PLIF and divided them into cage subsidence group and nonsubsidence group. The differences in preoperative HU value and forearm T-score were compared between groups, and the correlation between cage subsidence and clinical efficacy was analyzed. RESULTS The subsidence rate for all 71 patients (31 men and 40 women) was 23.9%. There was no significant difference in age, sex ratio, body mass index, smoking status, follow-up time, spine BMD, and spine T-score between groups, except in the forearm T-score and lumbar spine HU values (P < 0.05). The forearm T-score (AUC, 0.840; 95% CI, 0.672-1.000) predicted cage subsidence more accurately than the mean global HU value (AUC, 0.744; 95% CI, 0.544-0.943). In logistic regression analysis, both forearm T-score and mean global HU value were found to be independent risk factors for cage subsidence (P < 0.05). CONCLUSIONS Lower forearm T-scores and lower lumbar spine HU values were significantly associated with the occurrence of cage subsidence. Lower forearm T-scores indicated a higher risk of cage subsidence than lumbar spine HU values. Forearm T-score is more effective in predicting cage subsidence than spine T-score. Therefore, forearm dual-energy X-ray absorptiometry may be a fast, simple, and reliable method for predicting cage subsidence following PLIF. However, our results suggest that the degree of cage subsidence is not associated with clinical efficacy.
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Affiliation(s)
- Hong-yu Pu
- grid.413387.a0000 0004 1758 177XDepartment of Orthopaedic Surgery, the Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China Sichuan Province
| | - Qian Chen
- grid.413387.a0000 0004 1758 177XDepartment of Orthopaedic Surgery, the Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China Sichuan Province
| | - Kun Huang
- grid.413387.a0000 0004 1758 177XDepartment of Orthopaedic Surgery, the Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China Sichuan Province
| | - Rui Zeng
- grid.488387.8The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000 Sichuan Province China
| | - Peng Wei
- grid.413387.a0000 0004 1758 177XDepartment of Orthopaedic Surgery, the Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China Sichuan Province
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14
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Surgeon Learning Curve and Clinical Outcomes of Minimally Invasive Anterior Lumbar Interbody Fusion With Posterior Percutaneous Instrumentation. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202212000-00003. [PMID: 36732304 PMCID: PMC9726293 DOI: 10.5435/jaaosglobal-d-22-00207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/07/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study reports the learning phase of the minimally invasive anterior lumbar interbody fusion (mini-ALIF) approach with a vascular and orthopaedic spine surgeon team. METHODS Adult patients who underwent primary mini-ALIF at the lowest two segments of the lumbar spine (i.e., L4/5, L5/S1) between January 2010 and December 2018 were analyzed. RESULTS One hundred twenty-seven patients were included. There was no notable change in total surgical time over the study period. Estimated blood loss markedly decreased until stabilizing at case 30 and slowly declined thereafter. The mean estimated blood loss was 184 mL for L5/S1, 232 mL for L4/L5, and 458 mL for two-level mini-ALIF. There were 20 vascular issues requiring primary repair or packing. Vascular issues declined over time, with a rate of 32% in the first 25 cases and 0% in the last 25. The postoperative complication rate was highest in the first 25 cases (7 of 21 total complications). The odds ratio of vascular injury with body mass index (BMI) > 35 was 4.09 (1.4 to 11.7 confidence interval, P ≤ 0.008). Total surgical time and postoperative complications increased with increasing BMI. CONCLUSION Performance of the mini-ALIF approach is associated with a learning curve of 25 to 30 cases before complications begin to decline. BMI > 35 is associated with increased surgical time and complications.
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15
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Parisien A, Wai EK, ElSayed MS, Frei H. Subsidence of Spinal Fusion Cages: A Systematic Review. Int J Spine Surg 2022; 16:1103-1118. [PMID: 36289005 PMCID: PMC9807049 DOI: 10.14444/8363] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Although many research studies investigating subsidence of intervertebral fusion cages have been published, to our knowledge, no study has comprehensively compared cage subsidence among all lumbar intervertebral fusion (LIF) techniques. This study aimed to review the literature reporting evidence of cage subsidence linked to LIF. The amount of subsidence was compared and associated with the procedures and corresponding implants used, and the effect of cage subsidence on clinical outcomes was investigated. METHODS For this systematic review, the MEDLINE and PubMed databases were used to identify relevant studies. Search terms included lumbar, lumbar vertebrae, lumbar spine, cage, spinal fusion, prosthesis, prosthesis implantation, implantation, implants, interbody, spacer, and subsidence. Studies included in this review were those having more than 10 patients and reporting the amount of subsidence observed using computed tomography or x-ray imaging after surgery and at follow-up visits after a minimum of 6 weeks postsurgery. Data and scale definitions related to subsidence were extracted from articles for comparison of subsidence prevalence between the 5 LIF surgical procedures. RESULTS Forty articles were identified for inclusion. The review included data from 390 anterior lumbar intervertebral fusions (ALIFs), 2130 lateral lumbar intervertebral fusions (LLIFs), 560 posterior lumbar intervertebral fusions (PLIFs), 245 oblique lumbar intervertebral fusions (OLIFs), and 1634 transverse lumbar intervertebral fusions (TLIFs) for a total of 4959 patients who underwent LIF surgery. The minimum and maximum percentages of the number of patients having subsidence for each procedure in the included studies were as follows: ALIF stand-alone, 6% and 23.1%; LLIF stand-alone, 8.7% and 39.6%; LLIF with posterior fixation, 3.3% and 20.7%; OLIF with posterior fixation, 4.4% and 36.9%; PLIF with posterior fixation, 7.4% and 31.8%; and TLIF, 0.0% and 51.2%. CONCLUSIONS The number of patients experiencing subsidence varied between studies within each fusion procedure. Our findings indicate that all 5 surgical methods are at risk of subsidence. Overall, ALIF without posterior fixation resulted in the lowest reported subsidence occurrence among the 5 surgical approaches. There is conflicting evidence on the association between subsidence and negative clinical outcomes. CLINICAL RELEVANCE This review defines and compares subsidence incidence between all LIF procedures and investigates the risk of symptomatic clinical outcomes. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ariane Parisien
- Mechanical and Aerospace Engineering, Carleton University, Ottawa, Ontario, Canada
| | - Eugene K. Wai
- Orthopeadic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Mostafa S.A. ElSayed
- Mechanical and Aerospace Engineering, Carleton University, Ottawa, Ontario, Canada
| | - Hanspeter Frei
- Mechanical and Aerospace Engineering, Carleton University, Ottawa, Ontario, Canada, Hanspeter Frei, Mechanical and Aerospace Engineering, 3135 Mackenzie Carleton University, 1125 Colonel By Drive, Ottawa, Ontario K1S 5B6, Canada;
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16
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Kim DY, Kwon OH, Park JY. Comparison Between 3-Dimensional-Printed Titanium and Polyetheretherketone Cages: 1-Year Outcome After Minimally Invasive Transforaminal Interbody Fusion. Neurospine 2022; 19:524-532. [PMID: 36203279 PMCID: PMC9537857 DOI: 10.14245/ns.2244140.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Three-dimensional (3D)-printed titanium implants have been developed recently, but the utility is not yet proven. The aim of this study was to compare 3D-printed titanium and polyetheretherketone (PEEK) implants after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS Between October 2018 and September 2021, we retrospectively analyzed 83 patients who underwent single-level MIS-TLIF (3D-printed titanium, 40; PEEK, 43). Radiologic parameters were assessed with x-ray and computed tomography (CT) at postoperative 1 week, 6 months, and 1 year. Clinical status was evaluated using Oswestry Disability Index, visual analogue scale score, and Bridwell fusion grading was assessed on 6-month and 1-year postoperative CT. RESULTS There were no differences between the 2 groups in demographics and clinical outcomes. At 1-year of follow-up, the reported 3D-printed titanium fusion grades were grade I: 77.5% (31 patients), grade II: 17.5% (7 patients), and grade III: 5% (2 patients). The PEEK fusion grades were grade I: 51.2% (22 patients), grade II: 41.9% (18 patients), and grade III: 7.0% (3 patients). For overall fusion rate (grade I + II), there was no difference between the 2 cages (95.0% vs. 93.0%, p = 0.705), but grade I was reported at a higher incidence in 3D-printed titanium than PEEK (77.5% vs. 51.2%, p = 0.013). There was no difference between cages based on subsidence and complications. CONCLUSION There were no significant differences in the overall fusion rate for MIS-TLIF surgery between 3D-printed titanium and PEEK, but the fusion grade was better in 3D-printed titanium than in PEEK. Long-term follow-up is required to verify the effectiveness.
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Affiliation(s)
- Do-Yeon Kim
- Department of Neurosurgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - O-Hyuk Kwon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Corresponding Author Jeong-Yoon Park Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Room 505, 63 Eonju-ro 20-gil, Gangnam-gu, Seoul 06229, Korea
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Anterior spine surgery for the treatment of complex spine pathology: a state-of-the-art review. Spine Deform 2022; 10:973-989. [PMID: 35595968 DOI: 10.1007/s43390-022-00514-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
Abstract
The use of anterior spinal surgery for the treatment of spinal pathology has experienced a dramatic increase over the past decade. Long relegated to treat complicated anterior pathologies it has returned to mainstream spine surgery techniques for all types of conditions, providing a significant boost to the spine surgeons' armamentarium to address a wide variety of types of spinal diseases more effectively. Anterior surgery is useful whenever there is significant spinal pathology that requires direct visualization of the anterior vertebral column to best restore spinal alignment, structural integrity and neurologic function. These pathologies include spinal deformities, tumors, burst fractures, infections, vertebral avascular necrosis, pseudoarthrosis and other miscellaneous indications. Currently available approaches to the spine include transabdominal, paramedian retroperitoneal, lateral oblique retroperitoneal, thoracotomy, and thoracolumbar extensile. Most of the lumbar approaches are now done through a muscle splitting, minimalistic approach that has decreased their morbidity or more recently via tubular approaches, such as lateral lumbar interbody fusions or other ante-psoas approaches. New retractors, instrumentation, hyperlordotic implants, approved biologics and even image guidance for disc preparation and precise implant placement are all recent advances that will hopefully improve surgical outcomes in patients following anterior spinal surgery. Most importantly, these approaches require added expertise and training with a dedicated team consisting of an anteriorly trained spine surgeon working simultaneously with a dedicated vascular surgeon to ensure maximum safety and superior patient outcomes. This state of the review is dedicated to familiarizing practicing spine surgeons with the most commonly used anterior spinal approaches along with cutting-edge instrumentation and fusion techniques to improve their options for the treatment of difficult spinal pathologies.
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Benson JC, Lehman VT, Sebastian AS, Larson NA, Nassr A, Diehn FE, Wald JT, Murthy NS. Successful fusion versus pseudarthrosis after spinal instrumentation: a comprehensive imaging review. Neuroradiology 2022; 64:1719-1728. [PMID: 35701631 DOI: 10.1007/s00234-022-02992-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/02/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Following spinal instrumentation and fusion, differentiating between successful arthrodesis and pseudoarthrosis on imaging can be challenging. Interpretation of such examinations requires understanding both the expected evolution of postoperative findings and the subtle indicators of pseudoarthrosis across multiple imaging modalities. Due to this level of intricacy, many clinicians lack familiarity with the subject beyond the more rudimentary concepts. METHODS This review provides an in-depth overview of the imaging of the post-operative spine, with particular emphasis on differentiating between pseudoarthrosis and arthrodesis. RESULTS A comprehensive overview of imaging of the post-operative spine is given, including the most common imaging modalities utilized, the expected post-operative findings, imaging findings in pseudoarthrosis, and imaging definitions of fusion. CONCLUSION Differentiating between pseudoarthrosis and arthrodesis in the postoperative spine is complex, and requires a robust understanding of various findings across many different modalities.
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Affiliation(s)
- John C Benson
- Department of Radiology, Mayo Clinic, 723 6th St. SW , Rochester, MN, 55902, USA.
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 723 6th St. SW , Rochester, MN, 55902, USA
| | | | - Noelle A Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 723 6th St. SW , Rochester, MN, 55902, USA
| | - John T Wald
- Department of Radiology, Mayo Clinic, 723 6th St. SW , Rochester, MN, 55902, USA
| | - Naveen S Murthy
- Department of Radiology, Mayo Clinic, 723 6th St. SW , Rochester, MN, 55902, USA
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Falowski SM, Koga SF, Northcutt T, Garamszegi L, Leasure J, Block JE. Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage. Orthop Res Rev 2021; 13:281-288. [PMID: 34934366 PMCID: PMC8684416 DOI: 10.2147/orr.s339222] [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] [Received: 09/14/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022] Open
Abstract
With an increasingly aging population globally, a confluence has emerged between the rising prevalence of degenerative spinal disease and osteoporosis. Fusion of the anterior spinal column remains the mainstay surgical intervention for many spinal degenerative disorders. However, decreased vertebral bone mineral density (BMD), quantitatively measured by dual x-ray absorptiometry (DXA), complicates treatment with surgical interbody fusion as weak underlying bone stock increases the risk of post-operative implant-related adverse events, including cage subsidence. There is a necessity for developing cages with advanced structural designs that incorporate bioengineering and architectural principles to tailor the interbody fusion device directly to the patient’s BMD status. Specifically, lattice-designed cages that mimic the web-like structure of native cancellous bone have demonstrated excellent resistance to post-operative subsidence. This article provides an introductory profile of a spinal interbody implant designed intentionally to simulate the lattice structure of human cancellous bone, with a similar modulus of elasticity, and specialized to match a patient’s bone status across the BMD continuum. The implant incorporates an open pore design where the degree of pore compactness directly corresponds to the patient’s DXA-defined BMD status, including patients with osteoporosis.
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Affiliation(s)
- Steven M Falowski
- Argires-Marotti Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | | | | | | | | | - Jon E Block
- Independent Clinical Consultant, San Francisco, CA, USA
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McGrath KA, Schmidt ES, Loss JG, Gillespie CM, Colbrunn RW, Butler RS, Steinmetz MP. Assessment of L5-S1 anterior lumbar interbody fusion stability in the setting of lengthening posterior instrumentation constructs: a cadaveric biomechanical study. J Neurosurg Spine 2021:1-9. [PMID: 34920420 DOI: 10.3171/2021.9.spine21821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Excessive stress and motion at the L5-S1 level can lead to degenerative changes, especially in patients with posterior instrumentation suprajacent to L5. Attention has turned to utilization of L5-S1 anterior lumbar interbody fusion (ALIF) to stabilize the lumbosacral junction. However, questions remain regarding the effectiveness of stand-alone ALIF in the setting of prior posterior instrumented fusions terminating at L5. The purpose of this study was to assess the biomechanical stability of an L5-S1 ALIF with increasing lengths of posterior thoracolumbar constructs. METHODS Seven human cadaveric spines (T9-sacrum) were instrumented with pedicle screws from T10 to L5 and mounted to a 6 degrees-of-freedom robot. Posterior fusion construct lengths (T10-L5, T12-L5, L2-5, and L4-5) were instrumented to each specimen, and torque-fusion level relationships were determined for each construct in flexion-extension, axial rotation, and lateral bending. A stand-alone L5-S1 ALIF was then instrumented, and L5-S1 motion was measured as increasing pure moments (2 to 12 Nm) were applied. Motion reduction was calculated by comparing L5-S1 motion across the ALIF and non-ALIF states. RESULTS The average motion at L5-S1 in axial rotation, flexion-extension, and lateral bending was assessed for each fusion construct with and without ALIF. After adding ALIF to a posterior fusion, L5-S1 motion was significantly reduced relative to the non-ALIF state in all but one fused surgical condition (p < 0.05). Longer fusions with ALIF produced larger L5-S1 motions, and in some cases resulted in motions higher than native state motion. CONCLUSIONS Posterior fusion constructs up to L4-5 could be appropriately stabilized by a stand-alone L5-S1 ALIF when using a nominal threshold of 80% reduction in native motion as a potential positive indicator of fusion. The results of this study allow conclusions to be drawn from a biomechanical standpoint; however, the clinical implications of these data are not well defined. These findings, when taken in appropriate clinical context, can be used to better guide clinicians seeking to treat L5-S1 pathology in patients with prior posterior thoracolumbar constructs.
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Affiliation(s)
- Kyle A McGrath
- 1Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland
| | - Eric S Schmidt
- 1Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland.,2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland
| | - Jeremy G Loss
- 3Lerner Research Institute, Cleveland Clinic, Cleveland; and
| | | | - Robb W Colbrunn
- 3Lerner Research Institute, Cleveland Clinic, Cleveland; and
| | - Robert S Butler
- 4Department of Quantitative Health Services, Cleveland Clinic, Cleveland, Ohio
| | - Michael P Steinmetz
- 1Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland.,2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland
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21
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Li Q, Long X, Shi L, Wang Y, Guan T, Lv J, Cai L. Prevalence and risk factors for cage subsidence after lumbar interbody fusion: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e28085. [PMID: 34889258 PMCID: PMC8663804 DOI: 10.1097/md.0000000000028085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Lumbar interbody fusion (LIF) is an effective treatment for lumbar degenerative diseases. Cage subsidence (CS) contitutes one of the most common postoperative complications. Many risk factors for CS after LIF have been reported in some studies. However, controversies still exist. The objective of this study will be to summarize data on the prevalence and risk factors of CS after LIF. METHODS AND ANALYSIS Our study present a protocol that conducted a systematic review and meta-analysis of prevalence and risk factors for CS after LIF. Two reviewers retrieved the relevant articles using the 5 databases (PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science) from inception to May 31st, 2021. Primary outcome will be the prevalence of CS after LIF. Second outcomes include the risk factors associated with postoperative CS and clinical outcomes associated with postoperative CS. Three reviewers will screen citation titles and abstracts and evaluated full-text of each potentially relevant citation, and then extracted the data using a data extraction form. Any discrepancies in decisions between reviewers will be resolved through discussion. We assessed the methodological quality and risk of bias of the included studies based on the Newcastle-Ottawa Quality Assessment Scale (NOS). The aim of the extra analysis is to explore the explanations of the heterogeneity (age, gender, race, year of publication, type of study and surgical procedure). Publication bias will be assessed by Begg test, Egger test and funnel plots. ETHICS AND DISSEMINATION No primary data will be collected and individual patient information and endangering participant rights, thus ethics approval is not required. Findings will be reported through publication and media. PROTOCOL REGISTRATION NUMBER PROSPERO CRD42021257981 (https://www.crd.york.ac.uk/PROSPERO/#joinuppage).
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Affiliation(s)
- Qiujiang Li
- Ningxia Medical University, Yinchuan, Ningxia, China
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Xingxia Long
- West China Hospital, Sichuan University, Sichuan, China
| | - Lin Shi
- Traditional Chinese Medicine Hospital Dianjiang Chongqing, Chongqing, China
| | - Yinbin Wang
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Tao Guan
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Jinhan Lv
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Lijun Cai
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
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22
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A biomechanical investigation of lumbar interbody fusion techniques. J Mech Behav Biomed Mater 2021; 125:104961. [PMID: 34781226 DOI: 10.1016/j.jmbbm.2021.104961] [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: 03/03/2020] [Revised: 11/01/2021] [Accepted: 11/06/2021] [Indexed: 11/24/2022]
Abstract
The anterior, posterior, transforaminal, and circumferential lumbar interbody fusions (ALIF, PLIF, TLIF, CLIF/360) are used to treat spondylolisthesis, trauma, and degenerative pathologies. This study aims to investigate the biomechanical effects of the lumbar interbody fusion techniques on the spine. A validated T12-sacrum lumbar spine finite-element model was used to simulate surgical fusion of L4-L5 segment using ALIF, PLIF with one and two cages, TLIF with unilateral and bilateral fixation, and CLIF/360. The models were simulated under pure-moment and combined (moment and compression) loadings to investigate the effect of different lumbar interbody fusion techniques on range of motion, forces transferred through the vertebral bodies, disc pressures, and endplate stresses. The range of motion of the lumbar spine was decreased the most for fusions with bilateral posterior instrumentations (TLIF, PLIF, and CLIF/360). The increase in forces transmitted through the vertebrae and increase in disc pressures were directly proportional to the range of motion. The discs superior to fusion were under higher pressure, which was attributed to adjacent segment degeneration in the superior discs. The increase in endplate stresses was directly proportional to the cross-sectional area and was greater in caudal endplates at the fusion level, which was attributed to cage subsidence. The response of the models was in line with overall clinical observations from the patients and can be further used for future studies, which aim to investigate the effect of geometrical and material variations in the spine. The model results will assist surgeons in making informed decisions when selecting fusion procedures based on biomechanical effects.
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23
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Breton Y, Lebhar J, Bourgoin A, Kriegel P, Chatellier P, Ropars M. Morbidity and clinicoradiological outcomes of anterior lumbar arthrodesis using tantalum intervertebral implants. Orthop Traumatol Surg Res 2021; 107:103030. [PMID: 34343698 DOI: 10.1016/j.otsr.2021.103030] [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] [Received: 09/07/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The objective of this study was to assess the morbidity of Anterior Lumbar Interbody Fusion (ALIF) using an intervertebral tantalum implant. Tantulum is an extremely porous metallic material which possesses properties of osseointegration, osteoinduction and osteoconduction while offering superior primary stability, compared to other materials more commonly used (polyether ether ketone or PEEK, titanium). Perioperative morbidity, short-term functional outcomes (2 years) and radiographic impaction of implants were also analysed. METHODS This retrospective monocentric study involved 94 patients operated on between 2014 and 2017 for degenerative disc disease (75%), degenerative spondylolisthesis (3%) or isthmic lytic spondylolisthesis (22%). Sixty-five patients (69%) had isolated ("stand-alone") ALIF procedures, 24 (26%) with associated anterior osteosynthesis and 5 (5%) with associated posterior osteosynthesis. A Kaplan-Meier survival curve was established with surgical revision listed as the main criterion for failure. Perioperative complications were identified. The clinical evaluation at the last follow-up used a Visual Analogue Scale for radicular pain (VAS-R), for lumbar pain (VAS-L) and the Oswestry Disability Index (ODI) score. The impactions, assessed on x-rays, were divided into 2 groups according to severity in order to establish risk factors (RF). RESULTS The primary objective showed a 2-year survival rate of 94% (95% CI [0.88; 0.99]). Two patients had early surgical revision for impaction and 4 patients had late surgical revision for pseudarthrosis. The rate of perioperative complications was 8.5%, mostly due to vascular causes. At the average follow-up of 33 months (24-59), the clinical results were significantly improved and the impaction rate was 36% in the immediate postoperative period (IPO) and 47% at one year. CONCLUSION ALIF using an intervertebral tantalum implant is a reliable, reproducible and low morbidity technique. However, it is accompanied by a significant rate of immediate and secondary impaction but without any resounding influence on short-term clinical outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yann Breton
- Orthopedics and Trauma department, Pontchaillou University Hospital, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Jonathan Lebhar
- ILO Rachis Institut Locomoteur de l'Ouest, 7 Boulevard de la Boutière, 35760 Saint-Grégoire, France
| | - Antoine Bourgoin
- Orthopedics and Trauma department, Pontchaillou University Hospital, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Pierre Kriegel
- Orthopedics and Trauma department, Pontchaillou University Hospital, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Patrick Chatellier
- Orthopedics and Trauma department, Pontchaillou University Hospital, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Mickaël Ropars
- Orthopedics and Trauma department, Pontchaillou University Hospital, 2 rue Henri le Guilloux, 35000 Rennes, France.
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Jones C, Okano I, Salzmann SN, Reisener MJ, Chiapparelli E, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Endplate volumetric bone mineral density is a predictor for cage subsidence following lateral lumbar interbody fusion: a risk factor analysis. Spine J 2021; 21:1729-1737. [PMID: 33716124 DOI: 10.1016/j.spinee.2021.02.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/11/2021] [Accepted: 02/28/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT It has been reported in previous studies that a decreased bone mineral density (BMD) as measured by dual X-ray absorptiometry (DXA) is associated with subsidence. However, there is limited research on the role of volumetric BMD (vBMD) as measured by quantitative computed tomography (QCT). Further, metabolic conditions such as obesity and type 2 diabetes have been associated with poor bone quality, but the impact of these metabolic conditions on on subsidence rates following lateral lumbar interbody fusion (LLIF) remains unclear. As such, risk factors for subsidence following LLIF is an area of ongoing research. PURPOSE The purpose of this study is to identify risk factors for subsidence following LLIF with a focus on metabolic conditions and vBMD as measured by QCT. STUDY DESIGN/SETTING Retrospective cohort study at a single academic institution. PATIENT SAMPLE Consecutive patients undergoing LLIF with or without posterior screws from 2014 to 2019 at a single academic institution who had a pre-operative CT and radiological imaging including radiographs or CT scans between 5 and 14 months post-operatively to assess for cage subsidence. OUTCOME MEASURE Subsidence prevalence following LLIF. METHODS We reviewed patients undergoing LLIF with or without posterior screws from 2014 to 2019 with a follow-up ≥5 months. Cage subsidence was assessed using the grading system by Marchi et al. Endplate volumetric BMD (EP-vBMD), vertebral bone volumetric BMD (VB-vBMD), BMI, and diabetes status were measured. Univariable analysis and multivariable logistic regression analyses with a generalized mixed model were conducted. Ad hoc analysis, including receiver operative characteristic curve analysis, was used for identifying the cut-off values in significant continuous variables for subsidence. Chi-Squared and ANOVA tests were used for categorical comparisons. RESULTS Five hundred sixty-seven levels in 347 patients were included in the final analysis. Mean age (± SD) was 61.7 ± 11.1yrs, 50.3% were male, and 89.6% were Caucasian. Subsidence was observed in 160 levels (28.2%). Multivariable analysis demonstrated an absence of posterior screws [OR = 2.854 (1.483 - 5.215), p=.001] and decreased EP-vBMD [0.996 (0.991 - 1.000), p=.032] were associated with an increased risk of subsidence. Increased BMI and diabetes status were not associated with increased rates of subsidence. Patients without posterior screws and low EP-vBMD experienced subsidence at 44.9% of levels. CONCLUSIONS Our results demonstrated that decreased EP-vBMD and standalone status were significantly associated with increased rates of subsidence following LLIF independent of BMI or diabetes status. Further analysis demonstrated that patients with a decreased EP-vBMD and without posterior screws experienced subsidence nearly 2.5 times higher than patients with no risk factors. In patients with a low EP-vBMD undergoing LLIF, posterior screws should be considered.
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Affiliation(s)
- Conor Jones
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | | | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th S, New York, NY 10021, USA..
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25
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Zhao L, Zeng J, Xie T, Pu X, Lu Y. [Advances in research on Cage subsidence following lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1063-1067. [PMID: 34387439 DOI: 10.7507/1002-1892.202104036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To summarize the advances in research on Cage subsidence following lumbar interbody fusion, and provide reference for its prevention. Methods The definition, development, clinical significance, and related risk factors of Cage subsidence following lumbar interbody fusion were throughout reviewed by referring to relevant domestic and doreign literature in recent years. Results At present, there is no consensus on the definition of Cage subsidence, and mostly accepted as the disk height reduction greater than 2 mm. Cage subsidence mainly occurs in the early postoperative stage, which weakens the radiological surgical outcome, and may further damage the effectiveness or even lead to surgical failure. Cage subsidence is closely related to the Cage size and its placement location, intraoperative endplate preparation, morphological matching of disk space to Cage, bone mineral density, body mass index, and so on. Conclusion The appropriate size and shape of the Cage usage, the posterolateral Cage placed, the gentle endplate operation to prevent injury, the active perioperative anti-osteoporosis treatment, and the education of patients to control body weight may help to prevent Cage subsidence and ensure good surgical results.
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Affiliation(s)
- Long Zhao
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jiancheng Zeng
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Tianhang Xie
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Xingxiao Pu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yufei Lu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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26
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Hunt JP, Begley MR, Block JE. Truss implant technology™ for interbody fusion in spinal degenerative disorders: profile of advanced structural design, mechanobiologic and performance characteristics. Expert Rev Med Devices 2021; 18:707-715. [PMID: 34160337 DOI: 10.1080/17434440.2021.1947244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Interbody fusion devices are customarily used in fusion of the anterior spinal column for treatment of degenerative disc disease. Their traditional role is to reestablish and maintain intervertebral disc height, contain bone graft and provide mechanical support for the spine while osseointegration takes place. Utilizing the principles of mechanobiology, a unique biokinetic interbody fusion device has been developed that employs an advanced structural design to facilitate and actively participate in the fusion consolidation process.Areas covered: This article profiles and characterizes 4WEB Medical's Truss Implant Technology™ which includes a range of 3D-printed titanium spinal interbody implants and non-spinal implants whose design is based on truss structures enabled by advances in additive manufacturing. Four main areas of the implant design and functionality are detailed: bio-architecture, mechanobiologic underpinnings, bioactive surface features, and subsidence resistance. Pre-clinical and clinical examples are provided to describe and specify the bioactive roles and contributions of each design feature.Expert opinion: The distinct and unique combination of features incorporated within the truss cage design results in a biokinetic implant that actively participates in the bone healing cascade and fusion process.
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Affiliation(s)
| | - Matthew R Begley
- Department of Engineering, University of California, Santa Barbara, Santa Barbara, USA
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Neal MT, Curley KL, Richards AE, Kalani MA, Lyons MK, Davila VJ. An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20107. [PMID: 36033916 PMCID: PMC9394109 DOI: 10.3171/case20107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/20/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUNDAnterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections.OBSERVATIONSThe authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures.LESSONSWhen retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.
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Aleinik AY, Mlyavykh SG, Qureshi S. Lumbar Spinal Fusion Using Lateral Oblique (Pre-psoas) Approach (Review). Sovrem Tekhnologii Med 2021; 13:70-81. [PMID: 35265352 PMCID: PMC8858408 DOI: 10.17691/stm2021.13.5.09] [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: 09/21/2021] [Indexed: 11/14/2022] Open
Abstract
Lumbar spinal fusion is one of the most common operations in spinal surgery. For its implementation, anterolateral (pre-psoas) approach (oblique lumbar interbody fusion, OLIF) is now increasingly used due to its high efficacy and safety. However, there is still little information on the clinical and radiological results of using this technique. The aim of the study was to analyze the safety and efficacy of OLIF in the treatment of lumbar spine disorders as presented in the literature.
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Affiliation(s)
- A Ya Aleinik
- Neurosurgeon, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S G Mlyavykh
- Director of the Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S Qureshi
- Associate Attending Orthopedic Surgeon Hospital for Special Surgery, 535 East 70 St., New York, NY, 10021, USA;; Associate Professor of Orthopedic Surgery Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
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Kalani MA, Kouloumberis P, Richards AE, Lyons MK, Davila VJ, Neal MT. Retrospective radiographic analysis of anterior lumbar fusion for high grade lumbar spondylolisthesis. JOURNAL OF SPINE SURGERY (HONG KONG) 2020; 6:650-658. [PMID: 33447667 PMCID: PMC7797809 DOI: 10.21037/jss-20-597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/16/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND High-grade spondylolisthesis (>50% slippage) is infrequently encountered in adults and frequently requires surgical treatment. The optimal surgical treatment is controversial with limited literature guidance as to optimal approach to treatment. An observational study to examine the technique and radiographic outcomes of adult patients treated with anterior lumbar interbody fusion (ALIF) and posterior percutaneous instrumentation for high-grade spondylolisthesis. METHODS ALIF was performed in 5 consecutive patients (3/5 female, 2/5 male) aged 29-67 years old who presented with low back pain and L5 radiculopathy. All patients failed conservative treatment and were treated with L4-5 and L5-S1 ALIF followed by posterior percutaneous L4-S1 pedicle screw and rod fixation. Pre- and postoperative clinical data was collected including L5-S1 posterior disk height in millimeters, millimeters of spondylolisthesis at L5-S1, degrees of segmental lordosis (L4-S1), lumbar lordosis (L1-S1), and lumbar lordosis pelvic incidence (LL-PI) mismatch. RESULTS Six weeks following surgery, no patient reported residual L5 radicular symptoms. At last follow up, patient satisfaction, according to Modified Macnab Criteria, was excellent in 4/5 patients and good in 1/5 patient. In the 4 patients with greater than 1 year radiographic follow up, fusion rate was 100% on computed tomography (CT). Mean increase in posterior disk height was 12.5 mm (range, 11.4-13.5 mm). Mean reduction in spondylolisthesis was 58.7% (range, 20.2-100%). Mean segmental (L4-S1) and overall (L1-S1) lumbar lordosis increased by 23.6% (range, 6.5-41.7%) and 16.6% (2.5-31.5%), respectively. Following surgery, LL-PI mismatch decreased from a mean of 16.4 to 10.2 degrees. CONCLUSIONS ALIF with posterior percutaneous instrumentation is a safe and effective treatment for high-grade lumbosacral spondylolisthesis in properly selected adults. This technique improves lumbar sagittal parameters and reduces spondylolisthesis. The indirect neural decompression from simultaneous disk height restoration and spondylolisthesis reduction may be associated with lower neurological injury rate compared to posterior-only. Future prospective study is needed to validate this hypothesis.
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Affiliation(s)
| | | | | | - Mark K Lyons
- Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, USA
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Cheung MY, Cheung P. Oblique lumbar interbody fusion in management of lumbar degenerative spinal stenosis in Chinese population. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720923058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: The purpose of this study was to assess the outcomes of a cohort of local Chinese patients who underwent oblique lumbar interbody fusion (OLIF) surgery for lumbar degenerative diseases. Methods: We adopted a minimally invasive anterior approach to the lumbar spine through retroperitoneal access. In the first part of the surgery, a 3- to 5-cm left lateral incision over the abdomen was made guided by imaging. L2–L5 disc space was approached via the corridor between the left psoas muscle and the great vessels. A specially designed interbody cage filled with bone substitute was utilized for interbody fusion. In the second part of the surgery, posterior instrumentation with or without decompression, was performed in a prone position. Efficacy and safety of the surgery were studied. Results: A total of 60 patients with the mean age of 68 years underwent OLIF at 83 surgical levels. Their mean operative time was 79 min, and the average blood loss was 84 ml for the OLIF part. The mean length of hospital stay was 5.5 days. Based on plain computed tomography scan obtained at post-operative 6 months, successful fusion was achieved in 82 of the 83 surgical levels. The Oswestry Disability Index for low back pain had a mean reduction of 22.3% after 6 months. Specific complications observed include transient thigh pain or numbness, retroperitoneal hematoma, post-operative ileus and Bone Morphogenetic Protein (BMP) osteolysis. None of the patients experienced infection, symptomatic pseudo-arthrosis, hardware failure, vascular injury, nerve injury, ureteral injury, bowel injury, incisional hernia or death. Conclusion: OLIF is an effective procedure to treat lumbar spinal stenosis and spondylolisthesis with excellent fusion rate and good functional outcome. Complications specific to this procedure are not uncommon, but majority are minor and self-recovery. Proper training is required to minimize potential surgical risks.
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Affiliation(s)
- Man Yee Cheung
- Department of Orthopaedics & Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Philip Cheung
- Department of Orthopaedics & Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
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Ahlquist S, Thommen R, Park HY, Sheppard W, James K, Lord E, Shamie AN, Park DY. Implications of sagittal alignment and complication profile with stand-alone anterior lumbar interbody fusion versus anterior posterior lumbar fusion. JOURNAL OF SPINE SURGERY 2020; 6:659-669. [PMID: 33447668 DOI: 10.21037/jss-20-595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Anterior lumbar interbody fusion (ALIF) is commonly utilized in lumbar degenerative pathologies. Standalone ALIF (ST-ALIF) systems were developed to avoid added morbidity, surgical time, and cost of anterior and posterior fusion (APF). Controversy exists in the literature about which of these two techniques yields superior clinical and radiographic outcomes, and few studies have directly compared them. This study seeks to compare ST-ALIF and APF in terms of sagittal correction and surgical complications. Methods Ninty-two consecutive ALIF cases performed from 2013-2018 were retrospectively reviewed and separated into 2 groups. Radiographic measurements were performed on pre- and post-operative radiographs, including segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL). Surgical complications were determined. Statistical analysis was performed using chi-square test of homogeneity, Fisher's exact test, and independent sample t-test. Comparisons between groups were deemed statistically significant at the P<0.05 threshold. Results Fifty-seven ST-ALIF, 35 APF were identified. There were no differences in age, gender, BMI, Charlson Comorbidity Index (CCI), preoperative diagnosis, or surgical level between the 2 cohorts. Bone Morphogenetic Protein (BMP) was utilized in 24.6% of ST-ALIF versus none of APF (P=0.001). No differences were detected in SL, LL, and PI-LL mismatch. ST-ALIF cohort had significantly greater risk of subsidence and revision surgery versus APF (12.3% vs. 0%, RD 95% CI: 3.8-20.8%, P=0.042). Recurrent spondylolisthesis occurred in 5 ST-ALIF cases, 3 cases with implant failure, and 2 nonunions versus none in the APF group. Conclusions ST-ALIF was associated with significantly greater subsidence and revision surgery versus APF. Careful patient selection is paramount when considering ST-ALIF. The potential for revision surgery may offset the potential benefit in avoiding posterior fusion. Despite the greater risk of subsidence, sagittal alignment was not significantly affected.
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Affiliation(s)
- Seth Ahlquist
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Rachel Thommen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Howard Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - William Sheppard
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Kevin James
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Elizabeth Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Arya N Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
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Collino RR, Kiapour A, Begley MR. Subsidence of Additively-Manufactured Cages in Foam Substrates: Effect of Contact Topology. J Biomech Eng 2020; 142:091003. [PMID: 32140715 DOI: 10.1115/1.4046584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Indexed: 07/25/2024]
Abstract
Subsidence of implants into bone is a major source of morbidity. The underlying mechanics of the phenomenon are not clear, but are likely related to interactions between contact stresses and the underlying porous trabecular bone structure. To gain insight into these interactions, we studied the penetration of three-dimensional (3D)-printed indenters with systematically varying geometries into Sawbones® foam substrates and isolated the effects of contact geometry from those of overall contact size and area. When size, contact area, and indented material stiffness and strength are controlled for, we show that resistance to penetration is in fact a function of topology only. Indenters with greater line contact lengths support higher subsidence loads in compression. These results have direct implications for the design of implants to resist subsidence into bone.
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Affiliation(s)
- Rachel R Collino
- Materials Science and Technology Division, Los Alamos National Laboratory, Los Alamos, NM 87545
| | - Ali Kiapour
- Research & Development 4WEB Medical, Inc., Frisco, TX 75034
| | - Matthew R Begley
- Departments of Mechanical Engineering and Materials, University of California, Santa Barbara, CA 93106
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Verma R, Virk S, Qureshi S. Interbody Fusions in the Lumbar Spine: A Review. HSS J 2020; 16:162-167. [PMID: 32523484 PMCID: PMC7253570 DOI: 10.1007/s11420-019-09737-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height. QUESTIONS/PURPOSES We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine. METHODS Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review. RESULTS Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK-titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation. CONCLUSIONS All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.
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Affiliation(s)
- Ravi Verma
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
| | - Sohrab Virk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
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Lee DG, Park CK, Lee DC. Clinical and radiological comparison of 2 level anterior lumbar interbody fusion with posterolateral fusion and percutaneous pedicle screw in elderly patients with osteoporosis. Medicine (Baltimore) 2020; 99:e19205. [PMID: 32150059 PMCID: PMC7478679 DOI: 10.1097/md.0000000000019205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Retrospective observational cohort study.We used observational measures and retrospective chart reviews to compare elderly patients with osteoporosis who underwent multi-level anterior lumbar interbody fusion (ALIF) with either posterolateral fusion (PLF) or percutaneous pedicle screw fixation.Multi-level ALIF with PLF is used to save the posterior element of the spine and improve fusion rates in elderly patients with osteoporosis. To minimize perioperative invasiveness and improve patients' postoperative quality of life, we perform minimal percutaneous screw fixation.Fifty-three elderly patients with osteoporosis who underwent either PLF with open pedicle screw fixation (n = 28) or percutaneous pedicle screw fixation (PPF) (n = 25) for treatment with 2-level ALIF between January 2010 and December 2013 were compared for clinical outcome including operation time, intraoperative and postoperative blood loss, and hospital day and radiological outcome.Average operation times were significantly shorter and intra- and postoperative blood loss was significantly reduced in the PPF group. There were no significant differences, preoperative and postoperative, in observational measures including visual analog scale, Oswestry disability index, and Rolland-Moris disability. There were no significant differences in the degree of lordosis, changes of motion, or adjacent segmental degeneration. Fusion rates were increased in the PLF group compared to the PPF group 6 months post-surgery, but from 1 year to the last follow-up, the rates were statistically equivalent. There were fewer minor complications in the PPF group, and no major complications at all.Two-level ALIF with PPF results in shorter operation times, less blood loss and minor complications, and similar fusion rate as 2-level ALIF with PLF. It; therefore, represents an effective method, leading to rapid recovery and less complications in elderly patients with osteoporosis.
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Affiliation(s)
- Dong Geun Lee
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon
| | - Choon Keun Park
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon
| | - Dong Chan Lee
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Anyang, South Korea
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Onishi FJ, de Paiva Neto MA, Cavalheiro S, Centeno RS. Morphometric analysis of 900 lumbar intervertebral discs: Anterior and posterior height analysis and their ratio. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Goodnough LH, Koltsov J, Wang T, Xiong G, Nathan K, Cheng I. Decreased estimated blood loss in lateral trans-psoas versus anterior approach to lumbar interbody fusion for degenerative spondylolisthesis. JOURNAL OF SPINE SURGERY 2019; 5:185-193. [PMID: 31380471 DOI: 10.21037/jss.2019.05.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The goal of the current study was to compare the perioperative and post-operative outcomes of eXtreme lateral trans-psoas approach (XLIF) versus anterior lumbar interbody fusion (ALIF) for single level degenerative spondylolisthesis. The ideal approach for degenerative spondylolisthesis remains controversial. Methods Consecutive patients undergoing single level XLIF (n=21) or ALIF (n=54) for L4-5 degenerative spondylolisthesis between 2008-2012 from a single academic center were retrospectively reviewed. Groups were compared for peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), radiographic measurements (L1-S1 cobb angle, disc height, fusion grade, subsidence), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index). Results Estimated blood loss was significantly lower for XLIF [median 100; interquartile range (IQR), 50-100 mL] than for ALIF (median 250; IQR, 150-400 mL; P<0.001), including after adjusting for significantly higher rates of posterior decompression in the ALIF group. There were no significant differences in rates of complications within 30 days, radiographic outcomes, or in re-operation rates. Both groups experienced significant pain relief post-operatively. Conclusions The lateral trans-psoas approach is associated with diminished blood loss compared to the anterior approach in the treatment of degenerative spondylolisthesis. We were unable to detect differences in radiographic outcomes, complication rates, or patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. Further studies will continue to define indications for lateral versus anterior approach to lumbar spine for degenerative spondylolisthesis.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Jayme Koltsov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Tianyi Wang
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Grace Xiong
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Karthik Nathan
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
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Kapustka B, Kiwic G, Chodakowski P, Miodoński JP, Wysokiński T, Łączyński M, Paruzel K, Kotas A, Marcol W. Anterior lumbar interbody fusion (ALIF): biometrical results and own experiences. Neurosurg Rev 2019; 43:687-693. [PMID: 31111262 PMCID: PMC7186239 DOI: 10.1007/s10143-019-01108-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/26/2019] [Accepted: 04/16/2019] [Indexed: 11/26/2022]
Abstract
Lumbar fusion is a mainstay in the treatment of low back pain resulting from degenerative disc disease. Anterior lumbar interbody fusion (ALIF) has become a reasonable treatment technique to achieve indirect foraminal decompression with high fusion rates. The aim of the study was to analyse the biometrical parameters of the lumbar spine and the clinical outcome. The medical records of 51 patients treated with ALIF between 2012 and 2016 were retrospectively reviewed. Anterior and posterior disc height (DH), lumbar lordosis (LL), local disc angle (LDA) and foraminal dimensions were obtained on pre- and postoperative plain radiographs and computed tomography scans using ImageJ and Surgimap software according to the pedicle–pedicle technique. To evaluate the interbody fusion status on the last follow-up CT scans, we used Bridwell criteria. Preoperative and 12 months postoperative Oswestry Disability Index (ODI) scores were determined for all patients. The average length of hospitalisation was 4 days. Most of the patients had degenerative disc disease with foraminal stenosis. Five patients had early complications like paresthesia of lower limbs, sympathetic dysfunction or wound infections, but there were no major complications. Statistically significant (P < .01) improvement was observed in foraminal dimensions (area = 49%, height = 33% and width = 19%), anterior DH (49%), posterior DH (69%), LDA (47%) and LL (17.5%). Posterior DH correlated significantly with foramen height improvement. Radiographic evidence of fusion according to the modified Bridwell criteria (grade I and grade II) was observed in 96% (49/51) of the patients in the last CT of the lumbar spine. We also observed significant improvement in functional recovery in 94% of patients. The mini-open ALIF approach is a reasonable alternative to the more extensive posterior approaches. ALIF significantly restores the height of the intervertebral disc, indirectly increases foraminal dimensions, increases lordosis angle with significant short and long-term pain relief and functional recovery.
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Affiliation(s)
- Bartosz Kapustka
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Grzegorz Kiwic
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Paweł Chodakowski
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Jan P Miodoński
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Tomasz Wysokiński
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Mariusz Łączyński
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland
| | - Krzysztof Paruzel
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Adrian Kotas
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Wiesław Marcol
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland.
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland.
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Scherman DB, Rao PJ, Phan K, Mungovan SF, Faulder K, Dandie G. Outcomes of direct lateral interbody fusion (DLIF) in an Australian cohort. JOURNAL OF SPINE SURGERY 2019; 5:1-12. [PMID: 31032433 DOI: 10.21037/jss.2019.01.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Direct lateral interbody fusion (DLIF) mitigates many of the vascular complications and bony resections associated with other interbody fusion techniques. However, there are concerns regarding postoperative neural complications and that indirect decompression of the foramen has not been consistently demonstrated. This study prospectively assessed the clinical and radiological outcomes and the complication rates of the DLIF approach. Methods A prospective review was conducted of the first 50 consecutive DLIF cases of a single neurosurgeon between 2010 and 2014. Clinical outcomes were assessed using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) surveys. Radiological outcomes, including spondylolisthesis, disc height, local disc angle, lumbar lordosis and foraminal height and width, were measured using Surgimap Spine software at the preoperative, 6 weeks, 6 months, and 12 months postoperative follow-up. Complication rates were also reported. Results A total of 50 patients (84 levels) were treated with DLIF. The mean patient age was 68.2±9.8 years and 62.0% were female. At latest follow-up, mean VAS pain score improved from 7.7±1.5 to 1.9±0.9 (P<0.0001), mean ODI improved from 42.1±14.5 to 16.9±6.7 (P<0.0001) and mean RMDQ score improved from 12.1±5.2 to 6.2±4.7 (P<0.0001). Mean spondylolisthesis reduced from 7.5%±6.5% to 1.3%±1.1% at 6 weeks (P<0.0001), 0.95%±0.74% at 6 months (P<0.0001) and recurred to 1.9%±1.7% at 12 months postoperatively (P=0.0006). Mean anterior disc height improved from 7.3±3.2 to 11.6±2.5 mm at 6 weeks (P<0.0001), 12.2±3.3 mm at 6 months (P<0.0001) and 9.8±2.1 mm at 12 months (P=0.0032) postoperatively. Mean posterior disc height improved from 4.4±2.0 to 6.8±2.1 mm at 6 weeks (P<0.0001), 6.6±2.5 mm at 6 months (P=0.0003), and 5.9±1.4 mm at 12 months (P=0.0039) postoperatively. Mean local disc angle improved from 7.0°±3.7° to 9.2°±3.3° at 6 weeks (P=0.0072), 10.4°±3.9° at 6 months (P=0.0013) and 8.2°±2.9° at 12 months (P=0.2487) postoperatively. No significant postoperative changes in lumbar lordosis were observed. Mean foraminal height improved from 18.3±3.5 to 21.5±3.9 mm at 6 weeks (P=0.0004), 20.6±3.4 mm at 6 months (P=0.0266), and 18.7±1.9 mm at 12 months (P=0.8021) postoperatively. Mean foraminal width improved from 7.9±2.0 to 10.2±2.8 mm at 6 weeks (P=0.0001), 9.4±2.6 mm at 6 months (P=0.0219) and 8.3±1.6 mm at 12 months (P=0.5734) postoperatively. Fusion rate at 6 and 12 months was 62.2% and 89.2%, respectively. A total of 6 patients (12%) had postoperative complications. Three patients (6%) had pain-related psoas muscle weakness and 3 patients (6%) had sensory neural complications that had resolved entirely by 8 and 16 weeks postoperatively, respectively. Conclusions The study provides encouraging short and medium-term clinical and radiological results for DLIF. In this patient series, there was a low complication rate with no permanent neural injury reported.
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Affiliation(s)
- Daniel B Scherman
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia.,Westmead Clinical School, C24 - Westmead Hospital, The University of Sydney, Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), University of New South Wales, Sydney, Australia
| | - Prashanth J Rao
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), University of New South Wales, Sydney, Australia
| | - Kevin Phan
- Westmead Clinical School, C24 - Westmead Hospital, The University of Sydney, Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), University of New South Wales, Sydney, Australia
| | - Sean F Mungovan
- Westmead Private Physiotherapy Services, The Clinical Research Institute, Sydney, Australia
| | - Kenneth Faulder
- Department of Radiology, Westmead Hospital, Sydney, Australia
| | - Gordon Dandie
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia.,Westmead Clinical School, C24 - Westmead Hospital, The University of Sydney, Sydney, Australia
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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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