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Mac-Thiong JM, Hresko MT, Alzakri A, Parent S, Sucato DJ, Lenke LG, Marks M, Goulet J, Labelle H. A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients. Clin Spine Surg 2023; 36:E442-E452. [PMID: 37482639 DOI: 10.1097/bsd.0000000000001499] [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: 09/26/2022] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
STUDY DESIGN Retrospective multicenter cohort-study. OBJECTIVE We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis. SUMMARY OF BACKGROUND DATA The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis. METHODS This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery. RESULTS The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage. CONCLUSIONS A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.
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Affiliation(s)
- Jean-Marc Mac-Thiong
- University of Montreal
- CHU Sainte-Justine
- Hôpital du Sacré-Coeur, Montreal, QC, Canada
| | | | - Abdulmajeed Alzakri
- University of Montreal
- CHU Sainte-Justine
- Hôpital du Sacré-Coeur, Montreal, QC, Canada
- Department of Orthopaedic, College of Medecine
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Stefan Parent
- University of Montreal
- CHU Sainte-Justine
- Hôpital du Sacré-Coeur, Montreal, QC, Canada
| | | | | | | | - Julien Goulet
- University of Montreal
- Hôpital du Sacré-Coeur, Montreal, QC, Canada
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Siegel N, Lambrechts MJ, Brush PL, Karamian B, Lee Y, Depalma M, Delvadia B, Song S, Toci GR, Canseco JA, Woods BI, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Do On-Table Radiographs Predict Postoperative Sagittal Alignment after Posterior Lumbar Fusion? World Neurosurg 2023; 174:e118-e125. [PMID: 36889640 DOI: 10.1016/j.wneu.2023.03.005] [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: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023]
Abstract
OBJECTIVE To determine if intraoperative on-table lumbar lordosis and segmental lordosis correlate with postoperative lordosis following single-level posterolateral decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF). METHODS Electronic medical records were reviewed for patients ≥18 years old who underwent PLDF or TLIF between 2012 and 2020. Lumbar lordosis and segmental lordosis were compared between pre-, intra-, and postoperative radiographs using paired t tests. Significance was set at P < 0.05. RESULTS A total of 200 patients met inclusion criteria. No significant differences in preoperative, intraoperative, or postoperative measurements were found between groups. Patients who underwent PLDF experienced less disc height loss over 1 year postoperatively (PLDF: 0.45 ± 0.9 mm vs. TLIF: 1.2 ± 1.4 mm, P < 0.001). Lumbar lordosis significantly decreased between intraoperative to postoperative radiographs at 2-6 weeks for PLDF (Δ: -4.0°, P < 0.001) and TLIF (Δ: -5.6°, P < 0.001), but no change was identified between the intraoperative and >6 month postoperative radiographs for PLDF (Δ: -0.3°, P = 0.634) or TLIF (Δ: -1.6°, P = 0.087). Segmental lordosis significantly increased from the preoperative to post-instrumentation intraoperative radiographs for PLDF (Δ: 2.7°, P < 0.001) and TLIF (Δ: 1.8°, P < 0.001), but it subsequently decreased at the final follow up for PLDF (Δ: -1.9°, P < 0.001) and TLIF (Δ: -2.3°, P < 0.001). CONCLUSIONS Subtle decreases in lumbar lordosis may be noticed in early postoperative radiographs compared with intraoperative images on Jackson operative tables. However, these changes are not present at 1-year follow-up as lumbar lordosis increases to a similar level as intraoperative fixation.
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Affiliation(s)
- Nicholas Siegel
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parker L Brush
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Karamian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yunsoo Lee
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Michael Depalma
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Bela Delvadia
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Steven Song
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory R Toci
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Vialle EN, Ramos GZ, Hinojosa FL, Guiroy A, Rocha LGDD, Arruda ADO. Correlation Between Cage Positioning and Lumbar Lordosis in Transforaminal Lumbar Interbody Fusion (TLIF). Rev Bras Ortop 2022; 57:821-827. [PMID: 36226212 PMCID: PMC9550357 DOI: 10.1055/s-0042-1756215] [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: 11/07/2021] [Accepted: 06/27/2022] [Indexed: 10/29/2022] Open
Abstract
Objective The present study evaluates radiographic outcomes and the lumbar lordosis achieved with a transforaminal lumbar interbody fusion (TLIF) arthrodesis technique according to the positioning of an interbody device (cage) in the disc space. Methods This is a retrospective radiographic analysis of single-level surgical patients with degenerative lumbar disease submitted to a TLIF procedure and posterior pedicle instrumentation. We divided patients into two groups according to cage positioning. For the TLIF-A group, the cages were anterior to the disc space; for the TLIF-P group, cages were posterior to the disc space. Considering the superior vertebral plateau of the lower vertebra included in the instrumentation, cages occupying a surface equal to the anterior 50% of the midline were placed in the TLIF-A group, and those in a posterior position were placed in the TLIF-P group. We assessed pre- and postoperative orthostatic lateral radiographs to obtain the following measures: lumbar lordosis (LL) (angle L1-S1), segmental lordosis (LS) (L4-S1), and segmental lordosis of the cage (SLC). Results The present study included 100 patients from 2011 to 2018; 44 were males, and 46 were females. Their mean age was 50.5 years old (range, 27 to 76 years old). In total, 43 cages were "anterior" (TLIF-A) and 57 were "posterior" (TLIF-P). After surgery, the mean findings for the TLIF-A group were the following: LL, 50.7°, SL 34.9°, and SLC 21.6°; in comparison, the findings for the TLIF-P group were the following: LL, 42.3° ( p < 0.01), SL 30.7° ( p < 0.05), and SLC 18.8° ( p > 0.05). Conclusion Cage positioning anterior to the disc space improved lumbar and segmental lordosis on radiographs compared with a posterior placement.
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Affiliation(s)
- Emiliano Neves Vialle
- Grupo de Cirurgia da Coluna, Departamento de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Curitiba, PR, Brasil
| | - Guilherme Zandavalli Ramos
- Grupo de Cirurgia da Coluna, Departamento de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Curitiba, PR, Brasil
| | - Fabian Lopez Hinojosa
- Grupo de Cirurgia da Coluna, Departamento de Ortopedia e Traumatologia, Hospital Angeles Valle Oriente, Monterrey, Nuevo León, México
| | - Alfredo Guiroy
- Unidad de Patología Espinal, Hospital Español de Mendoza, Mendoza, Argentina
| | | | - André de Oliveira Arruda
- Grupo de Cirurgia da Coluna, Departamento de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Curitiba, PR, Brasil,Endereço para correspondência André de Oliveira Arruda, MD, MSc Av. São José300, Curitiba, Paraná, 80050-350Brasil
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Kim CJ, Son SM, Choi SH, Ryu D, Lee C. Spinal stability analysis of lumbar interbody fusion according to pelvic type and cage angle based on simplified spinal model with various pelvic indices. Front Bioeng Biotechnol 2022; 10:1002276. [PMID: 36277403 PMCID: PMC9585289 DOI: 10.3389/fbioe.2022.1002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Recently, the objectives of lumbar interbody fusion (LIF) have been extended to include the correction of broader/relative indications in addition to spinal fixation. Accordingly, LIF must be optimized for sagittal alignment while simultaneously achieving decompression. Therefore, a representative model classified into three pelvic types, i.e., neutral pelvis (NP), anterior pelvis (AP), and retroverted pelvis (RP), was selected according to the pelvic index, and LIF was performed on each representative model to analyze Lumbar lordosis (LL) and the corresponding equivalent stress. The finite element (FE) model was based on a sagittal 2D X-ray image. The calculation efficiency and convergence were improved by simplifying the modeling of the vertebral body in general and its posterior portion in particular. Based on the position of the pelvis, according to the pelvic shape, images of patients were classified into three types: AP, RP, and NP. Subsequently, representative images were selected for each type. The fixation device used in the fusion model was a pedicle screw and a spinal rod of a general type. PEEK was used as the cage material, and the cage shape was varied by using three different cage angles: 0°, 4°, and 8°. Spinal mobility: The pelvic type with the highest range of motion (ROM) for the spine was the NP type; the AP type had the highest LL. Under a combination load, the NP type exhibited the highest lumbar flexibility (LF), which was 2.46° lower on average compared to the case where a pure moment was applied. Equivalent stress on the spinal fixation device: The equivalent stress acting on the vertebrae was lowest when cage 0 was used for the NP and AP type. For the RP type, the lowest equivalent stress on the vertebrae was observed when cage 4 was used. Finally, for the L5 upper endplate, the stress did not vary significantly for a given type of cage. In conclusion, there was no significant difference in ROM according to cage angle, and the highest ROM, LL and LF were shown in the pelvic shape of NP type. However, when comparing the results with other pelvic types, it was not possible to confirm that LF is completely dependent on LL and ROM.
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Affiliation(s)
- Cheol-Jeong Kim
- Department of Biomedical Engineering, Graduate School, Pusan National University, Busan, South Korea
| | - Seung Min Son
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Sung Hoon Choi
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Dongman Ryu
- Medical Research Institute, Pusan National University, Busan, South Korea
| | - Chiseung Lee
- Department of Convergence Medicine and Biomedical Engineering, School of Medicine, Pusan National University, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
- *Correspondence: Chiseung Lee,
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Mathew J, Cerpa M, Lee NJ, Boddapati V, Marciano G, Sardar ZM, Lenke LG. Comparing hyperlordotic and standard lordotic cages for achieving segmental lumbar lordosis during transforaminal lumbar interbody fusion in adult spinal deformity surgery. JOURNAL OF SPINE SURGERY 2021; 7:318-325. [PMID: 34734136 DOI: 10.21037/jss-21-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/02/2021] [Indexed: 11/06/2022]
Abstract
Background Few studies directly compare the effect of interbody cages with different degrees of lordosis in producing segmental lumbar lordosis (SLL) in the transforaminal lumbar interbody fusion (TLIF) procedure. Thus, we aimed to investigate changes in SLL in hyperlordotic cages compared to standard lordotic cages in open TLIF procedures. Methods Thirty-eight consecutive patients who received open TLIF procedures performed by a single surgeon between 2017 and 2018 were reviewed. Twenty patients had "hyperlordotic cages" (20° lordosis), while 18 patients had "standard lordotic cages" (6° lordosis). Twenty-three patients had one-level TLIF procedures and 15 had two-level TLIF. Standard radiographic measurements, including SLL were assessed preoperatively, postoperatively, and at 1-year follow-up. SLL was measured from the superior endplate of the cephalad vertebra to the inferior endplate of the caudal vertebra. Changes in SLL were compared using Student's and paired t-tests. Results In one- and two-level open TLIF, both hyperlordotic and standard lordotic cages produced significant improvement in SLL. Among those receiving a one-level TLIF, SLL increased 7.8° (P=0.024) in those with standard lordotic cages; it increased 8.2° (P=0.020) in those with hyperlordotic cages. Among those receiving a two-level TLIF, SLL increased 13.9° (P=0.032) in those with standard lordotic cages; it increased 8.8° (P=0.023) in those with hyperlordotic cages. However, the improvement in SLL was not significantly different between the two cage types in either one or two-level TLIF procedures (P=0.917, P=0.389). At 1-year follow-up, there was no significant change in SLL, among standard lordotic and hyperlordotic cages (P=0.501, P=0.781). Conclusions Although it is theorized that hyperlordotic cages would increase SLL during open TLIF procedures more than standard lordotic cages, our data failed to demonstrate that. As our study examined cases performed by a single surgeon immediately before and after adoption of these lordotic cages, it is likely that surgical technique is of equal or greater importance in improving SLL than the amount of lordosis designed into interbody cages.
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Affiliation(s)
- Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Gerard Marciano
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Zeeshan M Sardar
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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Lovecchio FC, Vaishnav AS, Steinhaus ME, Othman YA, Gang CH, Iyer S, McAnany SJ, Albert TJ, Qureshi SA. Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion? Neurosurg Focus 2021; 49:E17. [PMID: 32871566 DOI: 10.3171/2020.6.focus20393] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology. METHODS The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted. RESULTS A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016). CONCLUSIONS Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Steven J McAnany
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Todd J Albert
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Sheeraz A Qureshi
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
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Ha AS, Tuchman A, Matthew J, Lee N, Cerpa M, Lehman RA, Lenke LG. Intraoperative versus postoperative radiographic coronal balance for adult spinal deformity surgery. Spine Deform 2021; 9:1077-1084. [PMID: 33625662 DOI: 10.1007/s43390-021-00297-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Coronal malalignment in adult spinal deformity (ASD) has a close relationship with patient clinical outcomes. The purpose of this study is to evaluate the relationship between intra- and postoperative coronal radiographic parameters. A novel parameter, the central sacral pelvic line (CSPL), and its relation to the central sacral vertical line (CSVL) is explored. CSPL is a measure of spinal alignment referenced to the patient's pelvis as an intraoperative proxy for CSVL. CSVL is difficult to measure intraoperatively, because a C7-plumb line (referenced to gravity) cannot be drawn in the supine position. METHODS 47 subjects ≥ 18 years old undergoing a spinal fusion of ≥ 6 levels from 2015 to 2017 were enrolled. The CSPL is defined as the perpendicular line bisecting the midpoint of the line that connects the superior aspects of the acetabuli. Two metrics describing coronal alignment were derived from each radiograph: (1) horizontal distance between the C7-plumb line and the CSPL at C7 (C7-CSPL) and (2) horizontal distance between the C7-plumb line and CSVL (C7-CSVL). Pearson's correlation and linear regression analysis was used to study the relationship between the intraoperative C7-CSPL and the postoperative C7-CSVL. RESULTS On average, the intraoperative C7-CSPL distance was 32.1 mm, postoperative C7-CSPL 20.8 mm, and postoperative C7-CSVL 18.9 mm. 15/47 (32%) had intraoperative C7-CSPL measurements > 4 cm, requiring intraoperative correction. Of those 15, 10 patients (67%) still had a postoperative C7-CSVL < 4 cm. Linear regression modeling indicates that when intraoperative CSPL is < 7.7 cm on average, the postoperative C7-CSVL will < 4 cm-our threshold for adequate coronal alignment. Patients with intraoperative C7-CSPL > 5 cm had a 50% chance of having a postoperative C7-CSVL > 4 cm; patients with intraoperative C7-CSPL < 5 cm had a 3% chance of having coronal malalignment. There is a strong positive relationship between postoperative C7-CSPL and C7-CSVL (r = 0.80 and 0.85, respectively). CONCLUSION In adult spinal surgery, the intraoperative coronal alignment measured using the novel C7-CSPL distance correlates well with postoperative C7-CSVL distance. This gives the surgeon an objective measurement of the correction they need after assessing initial intraoperative imaging. Our findings suggest an intraoperative C7-CSPL distance < 5 cm as a threshold value to predict postoperative C7-CSVL < 4 cm in 97% of patients tested.
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Affiliation(s)
- Alex S Ha
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA
| | - Alexander Tuchman
- Department of Neurological Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Justin Matthew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA
| | - Nathan Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA
| | - Meghan Cerpa
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA.
| | - Ronald A Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine, Hospital At New York-Presbyterian, 5141 Broadway, New York, NY, 10034, USA
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Jung JM, Chung CK, Kim CH, Yang SH, Ko YS, Choi Y. Intraoperative Radiographs in Single-level Lateral Lumbar Interbody Fusion Can Predict Radiographic and Clinical Outcomes of Follow-up 2 Years After Surgery. Spine (Phila Pa 1976) 2021; 46:772-780. [PMID: 33337681 DOI: 10.1097/brs.0000000000003889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI Some of the improvements in DH, FH, and SLL achieved intraoperatively during lateral lumbar interbody fusion surgery were lost by the postoperative 1-week follow-up. An intraoperative radiograph can predict radiographic and clinical outcomes of the 2-year follow-up. The difference between preoperative DH and intraoperative DH should be >4.18 mm.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young San Ko
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Gelfand Y, Benton J, De la Garza-Ramos R, Yanamadala V, Yassari R, Kinon MD. Effect of Cage Type on Short-Term Radiographic Outcomes in Transforaminal Lumbar Interbody Fusion. World Neurosurg 2020; 141:e953-e958. [PMID: 32565381 DOI: 10.1016/j.wneu.2020.06.096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of expandable versus static cage type on radiographic outcomes in transforaminal lumbar interbody fusion (TLIF) has not been well studied in the literature. We studied the effect of 3 cage types on change in foraminal height (FH), disk height (DH), subsidence, and segmental lordosis (SL). METHODS We conducted a retrospective review of patients who underwent TLIF in a single institution from 2014 to 2019. The following 3 cage types were identified: banana cage, bullet, and expandable cage. Computed tomography (CT) scans of the lumbar spine or lumbar radiographs (when CT scan was not available) with 6-week follow-up time were used for radiographic assessment. RESULTS One hundred patients with 133 fused segments were identified. The average age was 60.9 years, and 40% were men. A banana cage was used in 19 segments (14.3%), a bullet cage was used in 47 (35.4%), and an expandable cage was used in 67 segments (50.4%). There were no significant differences in FH (average increase, 0.7 mm; P = 0.771), subsidence (average, 2.3 mm; P = 0.554), DH (average decrease, 1.0 mm; P = 0.769), or clinically significant subsidence (>4 mm; P = 0.174). Expandable cages demonstrated a positive 1.2° gain in SL, whereas both other cages demonstrated a decrease in SL on average (P = 0.05). This result held up on multivariate analysis (P = 0.031). CONCLUSIONS The average increase in the foraminal height in TLIF is small (0.7 mm) and is not different between the cage types; therefore, direct decompression is crucially important in this procedure. Although TLIF is often considered to be a kyphotic procedure, an expandable cage demonstrated superiority in terms of segmental lordosis improvement.
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Affiliation(s)
- Yaroslav Gelfand
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Joshua Benton
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rafael De la Garza-Ramos
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Vijay Yanamadala
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Reza Yassari
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Merritt D Kinon
- Spine Research Group, Department of Neurosurgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
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Janjua MB, Ackshota N, Arlet V. Technical Consideration for TLIF Cage Retrieval and Deformity Correction With Anterior Interbody Fusion in Lumbar Revision Surgeries. Spine Deform 2019; 7:633-640. [PMID: 31202382 DOI: 10.1016/j.jspd.2018.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 08/30/2018] [Accepted: 10/13/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Symptomatic pseudoarthrosis after transforaminal lumbar interbody fusion (TLIF) could result in sagittal malalignment. Revision posterior surgery with TLIF cage removal poses a challenge intraoperatively. The authors have proposed salvage anterior approach for cage removal and have discussed unique experience with the correction in their deformity patients. METHODS All patients with symptoms of clinical deformity or symptomatic pseudoarthrosis operated from January of 2012 to February of 2018 were included in the study. TLIF cage removal followed by anterior lumbar interbody fusion (ALIF) surgery was performed in all patients. Radiographic sagittal parameters including thoracic kyphosis (TK; T4-T12), sagittal vertical axis (SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), the mismatch between pelvic incidence (PI) and LL (PI-LL), sacral slope (SS), pelvic tilt (PT), and PI were analyzed. RESULTS 6 patients (mean age of 57 years, 83% female) underwent TLIF retrieval through anterior approach and ALIF with hyperlordotic cages (HLCs), followed by posterior spinal fusion surgery. Described technique entails use of tailored instruments with sequential gentle distraction of end plates with TLIF spreader could facilitate in the cage removal. Mean number of interbody levels fused pre as well as post were 1.5. The radiographic sagittal parameters from preoperative versus postoperative standing were as follows: T4-T12 TK, 16° vs. 37.6°; LL, -25° vs. -47.6°; PT, 36° vs. 26°; PI-LL, 35° vs. 12.4°; SVA, 12° vs. 5.6°; and TPA, 44° vs. 25°, with p<.001. Mean number of instrumented level fused were 8.1. Using linear regression analysis, change from pre-to postoperative standing in LL predicted pre-to postoperative change in SVA and TPA for global correction (R= -0.30 and -0.80, respectively). CONCLUSIONS Anterior approach is a suitable technique for TLIF cage removal while preserving the end plates for subsequent optimal interbody fusion at the index level in symptomatic pseudoarthrosis patients or those with clinical deformity. ALIF with HLCs with or without Ponte osteotomy can restore segmental and overall sagittal alignment.
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Affiliation(s)
- M Burhan Janjua
- Department of Orthopedic Surgery, University of Pennsylvania Hospital, 235 S 8th St., Washington West Bldg, 800 Spruce Street, Philadelphia, PA 19107, USA; Department of Neurosurgery, University of Pennsylvania Hospital, 235 S 8th St., Washington West Bldg, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Nissim Ackshota
- Department of Orthopedic Surgery, University of Pennsylvania Hospital, 235 S 8th St., Washington West Bldg, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Vincent Arlet
- Department of Orthopedic Surgery, University of Pennsylvania Hospital, 235 S 8th St., Washington West Bldg, 800 Spruce Street, Philadelphia, PA 19107, USA.
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[Safety and efficacy of an electron beam melting technique-manufactured titanium mesh cage for lumbar interbody fusion]. DER ORTHOPADE 2018; 48:150-156. [PMID: 30569206 DOI: 10.1007/s00132-018-03681-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Electron beam melting (EBM) technique enables cage design changes such as the integration of guide rails on the cage surface or a 3D matrix for osseointegration. A change in manufacturing technique or design can lead to a decreased fusion rate or impaired applicability. OBJECTIVE The aim of the present study was to evaluate cage handling, lordosis reconstruction capability, and fusion rate 1 year after surgery. MATERIALS AND METHODS In this study, 50 patients who had undergone minimally invasive transforaminal lumbar interbody fusion (TLIF) or open posterior lumbar interbody fusion (PLIF) using an EBM-manufactured cage were retrospectively included. Fusion evaluation was based on routinely performed CTs and flexion-extension radiographs 12 months postoperatively. Lumbar and segmental lordosis were compared between pre-, post, and 1‑year follow-up. Postoperative cage position was used for evaluation of cage handling. RESULTS The radiological fusion rate was 97% at the 1‑year follow-up. Two cages were placed into the endplates during surgery without an effect on fusion. In 31% of the cages, placement at the anterior third of the disk space was possible. Lumbar lordosis was improved by a mean of 5° and segmental lordosis by a mean of 4°. At final follow-up, 1° was lost in both parameters. No implant-associated complications were registered. CONCLUSION The implant is safe and leads to a very high fusion rate. A learning curve results from the fact that the cage follows a defined radius dictated by the guide rails. Addressing this, exact placement at the anterior endplate can be achieved.
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