Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction

Comparison of Complication Rates Between Transforaminal Interbody Fusion and Anteroposterior Fusion for One- or Two-Level Degenerative Lumbar Spine Surgery: A Propensity Score Matched Analysis

Introduction Although transforaminal interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) combined with posterior fusion (AP) have similar fusion rates, it is unclear if choice of approach has an impact on post-operative complications. Research question Is the incidence of residual leg and/or back pain requiring additional treatment after one- or two-level TLIF and AP similar? Material and methods Adult patients who underwent one- or two-level TLIF or AP for degenerative pathology were identified and matched using age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA), insurance status, smoking status, revision and number of levels fused. The incidence of radicular leg and back pain requiring emergency department visit/readmission or same level surgical intervention was compared between the two groups. Results Of the 319 TLIF and 288 AP cases, 119 cases in each cohort were matched. TLIF patients had shorter operative times (203 min vs 258 min, P<0.001) and hospital stays than the AP patients (3.76 days vs 4.98 days, P<0.001). The incidence of residual leg pain (7 vs 5, P=0.769) and back pain (13 vs 15, P=0.841) was similar between the two groups. Except for constipation, which was more common in the AP group, the incidence of complications was similar between the two groups. Conclusions Patients undergoing one- or two-level TLIF showed shorter operative time and hospital stay compared with those undergoing AP. The incidence of leg radiculopathy and back pain was similar between the two groups. Surgeons should consider these findings as part of the decision-making process regarding which approach to use in patients requiring a lumbar interbody fusion.

Coronal Alignment in Adult Spine Surgery

Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.

Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review

Background

Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined.

Purpose

To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis.

Methods

A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared.

Results

Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment.

Conclusions

Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.

Oblique lateral interbody fusion for lumbosacral fractional curve correction in degenerative lumbar scoliosis

PURPOSE

In combined anterior-posterior adult spinal deformity surgery, the optimal combination of anterior and posterior procedures remains unclear. We aimed to demonstrate the radiological outcomes and relevant factors in oblique lateral interbody fusion (OLIF) for lumbosacral fractional curve (FC) correction combined with open posterior surgery in degenerative lumbar scoliosis (DLS).

METHODS

This study involved 42 consecutive patients with DLS who had a major curve (MC) ≥ 20° and an FC (L4 to S1) ≥ 10°, and underwent a combined anterior-posterior surgery Changes in the MC, FC, coronal balance distance, type of coronal imbalance, coronal/sagittal disc angle at L4-5 and L5-S1, L4 and L5 tilt, and sagittal parameters were examined. The associations between FC correction and demographic, surgical, and radiological factors were analysed.

RESULTS

The FC decreased from 16.9 ± 7.3° preoperatively to 6.6 ± 4.4° at the last follow-up (P < 0.001). The coronal disc angle at L4-5 and L5-S1 were, respectively, 6.8 ± 2.2° and 6.0 ± 4.1° preoperatively and decreased to 2.2 ± 2.1 and 1.2 ± 1.3° at the last follow-up (both P < 0.001). The changes in FC were greater in uppermost instrumented level > T10 (P < 0.001), and associated with the preoperative FC (r = 0.820, P < 0.001), L4 tilt (r = 0.434, P = 0.007), and L5 tilt (r = 0.462, P = 0.003).

CONCLUSION

OLIF at the FC combined with open posterior surgery is an effective combined anterior-posterior correction strategy in DLS.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes

OBJECTIVE

This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI).

RESULTS

Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF.

CONCLUSIONS

Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Clinical and Radiologic Analysis of Minimally Invasive Anterior-Posterior Combined Surgery for Adult Spinal Deformity: Comparison of Oblique Lateral Interbody Fusion at L5/S1 (OLIF51) versus Transforaminal Interbody Fusion

Background and Objectives: Although adult spinal deformity (ASD) surgery brought about improvement in the quality of life of patients, it is accompanied by high invasiveness and several complications. Specifically, mechanical complications of rod fracture, instrumentation failures, and pseudarthrosis are still unsolved issues. To better improve these problems, oblique lateral interbody fusion at L5/S1 (OLIF51) was introduced in 2015 at my institution. The objective of this study was to compare the clinical and radiologic outcomes of anterior-posterior combined surgery for ASD between the use of OLIF51 and transforaminal interbody fusion (TLIF) at L5/S1. Materials and Methods: A total of 117 ASD patients received anterior-posterior correction surgeries either with the use of OLIF51 (35 patients) or L5/S1 TLIF (82 patients). In both groups, L1-5 OLIF and minimally invasive posterior procedures of hybrid or circumferential MIS were employed. The sagittal and coronal spinal alignment and spino-pelvic parameters were recorded preoperatively and at follow-up. The quality-of-life parameters and visual analogue scale were evaluated, as well as surgical complications at follow-up. Results: The average follow-up period was thirty months (13-84). The number of average fused segments was eight (4-12). The operation time and estimated blood loss were significantly lower in OLIF51 than in TLIF. The PI-LL mismatch, LLL, L5/S1 segmental lordosis, and L5 coronal tilt were significantly better in OLIF51 than TLIF. The complication rate was statistically equivalent between the two groups. Conclusions: The introduction of OLIF51 for adult spine deformity surgery led to a decrease in operation time and estimated blood loss, as well as improvement in sagittal and coronal correction compared to TLIF. The circumferential MIS correction and fusion with OLIF51 serve as an effective surgical modality which can be applied to many cases of adult spinal deformity.

The Lumbosacral Fractional Curve in Adult Degenerative Scoliosis

Spine surgeons are often faced with a profoundly difficult challenge in surgically treating adult degenerative scoliosis. Deformity correction surgery is complicated by the difficulty in offering extensive surgical corrections to the elderly, complication-prone population it commonly affects. As spine surgeons attempt to offer minimally invasive solutions to this disease process, the need for fusion of the fractional curve at L4, L5, and S1 may be discounted. A treatment strategy to identify, address, and treat the fractional curve with either open or minimally invasive techniques can lead to improved patient outcomes and decrease revision rates in this complicated pathologic process.

Percutaneous transforaminal endoscopic surgery (PTES) and mini-incision L5/S1 OLIF with a self-lock cage for the surgical treatment of L5 spondylolisthesis

OBJECTIVES

We reported thirteen cases of percutaneous transforaminal endoscopic surgery (PTES) under local anesthesia and mini-incision L5/S1 OLIF (OLIF51) with a self-lock cage for the treatment of L5 spondylolisthesis.

METHODS

From Jan 2019 to Feb 2020, the patients with L5 spondylolisthesis with nerve root symptoms undergoing PTES and OLIF51 were included in this study. PTES under local anesthesia was performed in a prone position, and OLIF51 with a self-lock cage and allograft was then undertaken through a left abdominal mini-incision and oblique retroperitoneal approach between bilateral iliac vessels with the external oblique, internal oblique and transverse abdominal muscles bluntly separated in turn for L5/S1 in a right oblique position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using the VAS, and the clinical outcomes were evaluated with the ODI before surgery and at the 2-year follow-up. The anterior and posterior intervertebral space height (AISH, PISH), lumbar lordotic, and surgical segmental lordotic angle (SLA) were measured on lumbar spine X-rays preoperatively and postoperatively. The fusion status was assessed according to Bridwell's fusion grades.

RESULTS

Thirteen cases of L5 spondylolisthesis were included. The operation duration was 49.1 ± 5.6 min for PTES and 73.6 ± 8.2 min for OLIF. There was blood loss of 25 (15-45) ml. The incision length was 7.5 ± 1.1 mm for PTES and 46.8 ± 3.8 mm for OLIF. The hospital stay was 5 (4-6) days, and the follow-up duration was 29 (24-37) months. For the clinical evaluation, the VAS of back and leg pain significantly dropped after surgery (p < 0.001), and the ODI significantly decreased from 64.7 ± 7.8% to 12.9 ± 4.3% 2 years after surgery (p < 0.001). AISH, PISH and SLA significantly improved after surgery (p < 0.05). Fusion grades based on the Bridwell grading system at the 2-year follow-up were grade I in 9 segments (69.2%) and grade II in 4 segments (30.8%). No patients had any form of permanent iatrogenic nerve damage or major complications. No failure of instruments was observed.

CONCLUSIONS

PTES and mini-incision OLIF51 with a self-lock cage is a viable option of minimally invasive surgery for L5 spondylolisthesis, which can achieve direct neurologic decompression, satisfactory fusion and hardly destroys the rectus abdominis and its sheath, paraspinal muscles and bone structures.

L5-S1 Pseudoarthrosis Rate with ALIF Versus TLIF in Adult Spinal Deformity Surgeries: A Retrospective Analysis of 100 Patients

OBJECTIVE

Lumbosacral pseudoarthrosis is a common complication following adult spine deformity (ASD) surgery. This study assessed the reoperation rate for L5-S1 pseudoarthrosis in the ASD population. Compared with transforaminal lumbar interbody fusions (TLIFs), we hypothesized that anterior lumbar interbody fusion (ALIF) would result in lower rates of L5-S1 pseudarthrosis.

METHODS

This is a single center study with patient data retrieved from a prospective ASD database. The patients had a long-segment fusion, ALIF or TLIF at the L5-S1 level with a 2-year follow-up and were divided into 2 groups (TLIF and ALIF). The study's primary outcome was to assess the difference in the reoperation rate for clinical pseudoarthrosis between the TLIF and the ALIF groups. The secondary outcomes measured the radiological pseudoarthrosis rate and identified risks for L5-S1 pseudoarthrosis development.

RESULTS

A total of 100 patients were included; 49 patients (mean age, 62.9 years; 77.5% females) were in TLIF and 51 patients (mean age, 64.4 years; 70.6% females) were in the ALIF group. Baseline characteristics were similar in both groups. Thirteen (13%) patients with L5-S1 pseudoarthrosis required reoperation. Clinical pseudoarthrosis was higher in the TLIF group than in the ALIF group (12/49 vs. 1/51; P < 0.001). Univariate analysis demonstrated a higher risk of L5-S1 pseudoarthrosis with TLIF than ALIF (risk ratio, 12.4; 95% confidence interval: 1.68-92.4; P < 0.001). Multivariate analysis revealed 4.86 times the risk of L5-S1 clinical pseudoarthrosis with TLIF than with ALIF (risk ratio, 4.86; 95% confidence interval 0.57-47; P = 0.17), but this ratio did not reach statistical significance.

CONCLUSIONS

No difference in reoperation risk for L5-S1 pseudarthrosis was observed based on the method of IF. rhBMP-2 was noted as a significant predictor.

Multisegment transforaminal lumbar interbody fusion (TLIF) combined with Ponte osteotomy in degenerative lumbar scoliosis (DLS) surgery: a minimum of five years' follow-up

PURPOSE

To evaluate the long-term clinical outcomes of degenerative lumbar scoliosis (DLS) with the administration of multisegment transforaminal lumbar interbody fusion (TLIF) combined with Ponte osteotomy long-level fixation fusion, as well as to identify the factors affecting health-related quality of life (HRQOL).

METHODS

This was a retrospective single-centre study involving comprehensive clinical data. The Oswestry Disability Index (ODI), visual analog scale (VAS) outcomes, and Scoliosis Research Society (SRS-22) questionnaire were recorded to assess HRQOL. A correlation analysis was performed to determine the association between HRQOL and radiographic parameters.

RESULTS

A total of 41 consecutive patients (15 males and 26 females) met the inclusion criteria with a follow-up of 8.62 ± 1.20 years. Factors associated with HRQOL were significantly improved post-operation. Global sagittal parameters, including the sagittal vertebral axis (SVA) and T1 pelvic angle (TPA), and local parameters, including apical vertebral translation (AVT) and apical vertebral rotation (AVR), were significantly improved at the last follow-up. Significantly strong correlations between each clinical and radiographic parameter were demonstrated. Moreover, a multiple linear regression analysis demonstrated that the differences in AVT and AVR were significantly correlated with the difference in lumbar lordosis (LL), which was significantly correlated with the differences in SVA and TPA.

CONCLUSION

The surgical treatment of DLS with multisegment TLIF accompanied by Ponte osteotomy and long-level fixations improved the quality of life of patients with a long-term effect. AVR correction is an important factor for LL restoration that significantly correlates with improvements in the sagittal balance parameters SVA and TPA, which are key factors for guaranteeing good HRQOL.

[Research progress of effect of cage height on outcomes of lumbar interbody fusion surgery]

Objective

To summarize the effect of cage height on outcomes of lumbar interbody fusion surgery and the importance of the cage height selection.

Methods

The related literature was widely reviewed to summarize the research progress on the complications caused by inappropriate height of the cage and the methods of selecting cage height.

Results

Inappropriate height of the cage can lead to endplate injury, cage subsidence, internal fixation failure, adjacent segmental degeneration, over-distraction related pain, insufficient indirect decompression, instability of operation segment, poor interbody fusion, poor sequence of spine, and cage displacement. At present, the selection of the cage height is based on the results of the intraoperative model test, which is reliable but high requirements for surgical experience and hard to standardize.

Conclusion

The inappropriate height of the cage may have an adverse impact on the postoperative outcome of patients. It is important to develop a selection standard of the cage height by screening the related influential factors.

Lumbar Lordosis Correction With Transforaminal Lumbar Interbody Fusion in Adult Spinal Deformity Patients with Minimum 2-Year Follow-up

OBJECTIVE

To determine the degree of lumbar lordosis (LL) correction possible via transforaminal lumbar interbody fusion (TLIF) in adult spinal deformity patients.

METHODS

A retrospective chart review identified patients ≥18 years of age with severe positive sagittal balance defined by the SRS-Schwab classification: pelvic incidence to LL mismatch >20°, sagittal vertical axis >9.5cm, and/or pelvic tilt >30°. All patients had surgery between 2013 to 2018 with a TLIF at L4-L5 and/or L5-S1 by the senior author (J.L.F.) with ≥2-years follow-up.

RESULTS

Sixty-one patients (18 men, 43 women) with 85 TLIFs were included with an average age of 66 years and average follow-up of 50 months. Average lumbar lordosis (L1-S1) improved from 27° preoperative to 48° postoperative and 45° at 2-year follow-up (P < 0.001). Average segmental lordosis at L4-L5 TLIF sites improved from 3° preoperative to 13° postoperative and persisted at 2-year follow-up (P < 0.001). Segmental lordosis at L5-S1 TLIF sites improved from 7° preoperative to 21° postoperative and 20° at 2-year follow-up (P < 0.001). Seventeen of the TLIFs (20%) had >20° of segmental lordosis improvement at long-term follow-up. The rate of revision surgery for pseudoarthrosis at the TLIF level was 5%.

CONCLUSIONS

Significant lordosis correction can be achieved through an open TLIF in patients with severe positive sagittal balance when utilizing meticulous deformity correction techniques, avoiding the added morbidity of an anterior approach or a 3-column osteotomy.