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Bernatz JT, Pumford A, Goh BC, Pinter ZW, Mikula AL, Michalopoulos GD, Bydon M, Huddleston P, Nassr AN, Freedman BA, Sebastian AS. MRI Vertebral Bone Quality Correlates With Interbody Cage Subsidence After Anterior Cervical Discectomy and Fusion. Clin Spine Surg 2024; 37:149-154. [PMID: 38706112 DOI: 10.1097/bsd.0000000000001623] [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: 10/04/2023] [Accepted: 03/07/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Retrospective observational study of consecutive patients. OBJECTIVE The purpose of the study was to evaluate VBQ as a predictor of interbody subsidence and to determine threshold values that portend increased risk of subsidence. SUMMARY OF BACKGROUND DATA Many risk factors have been reported for the subsidence of interbody cages in anterior cervical discectomy and fusion (ACDF). MRI Vertebral Bone Quality (VQB) is a relatively new radiographic parameter that can be easily obtained from preoperative MRI and has been shown to correlate with measurements of bone density such as DXA and CT Hounsfield Units. METHODS All patients who underwent 1- to 3-level ACDF using titanium interbodies with anterior plating between the years 2018 and 2020 at our tertiary referral center were included. Subsidence measurements were performed by 2 independent reviewers on CT scans obtained 6 months postoperatively. VBQ was measured on pre-operative sagittal T1 MRI by 2 independent reviewers, and values were averaged. RESULTS Eight-five fusion levels in 44 patients were included in the study. There were 32 levels (38%) with moderate subsidence and 12 levels with severe subsidence (14%). The average VBQ score in those patients with severe subsidence was significantly higher than those without subsidence (3.80 vs. 2.40, P<0.01). A threshold value of 3.2 was determined to be optimal for predicting subsidence (AUC=0.99) and had a sensitivity of 100% and a specificity of 94.1% in predicting subsidence. CONCLUSIONS VBQ strongly correlates with the subsidence of interbody grafts after ACDF. A threshold VBQ score value of 3.2 has excellent sensitivity and specificity for predicting subsidence. Spine surgeons can use VBQ as a readily available screening tool to identify patients at higher risk for subsidence. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
| | | | | | | | | | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
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Farber SH, Ehresman J, Lee BS. Novel Use of Bilateral Prone Transpsoas Approach for the Treatment of Transforaminal Interbody Fusion Pseudarthrosis and Interbody Cage Subsidence. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01043. [PMID: 38305422 DOI: 10.1227/ons.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/01/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pseudarthrosis is a complication after transforaminal lumbar interbody fusion (TLIF) that leads to recurrent symptoms and potential revision surgery. Subsidence of the interbody adds to the complexity of surgical revision. In addition, we report a novel technique for the treatment of TLIF pseudarthrosis with subsidence and propose an approach algorithm for TLIF cage removal. METHODS Cases of reoperation for TLIF pseudarthrosis were reviewed. We report a novel technique using a bilateral prone transpsoas (PTP) approach to remove a subsided TLIF cage and place a new lateral cage. An approach algorithm was developed based on the experience of TLIF cage removal. The patient was placed in the prone position with somatosensory evoked potential and electromyography monitoring. A PTP retractor was placed using standard techniques on the ipsilateral side of the previous TLIF. After the discectomy, the subsided TLIF cage was visualized but unable to be removed. The initial dilator was closed, and a second PTP retractor was placed on the contralateral side. After annulotomy and discectomy to circumferentially isolate the subsided cage, a box cutter was used to push and mobilize the TLIF cage from this contralateral side, which could then be pulled out from the ipsilateral side. A standard lateral interbody cage was then placed. RESULTS Retractor time was less than 10 minutes on each side. The patient's symptoms resolved postoperatively. We review illustrative cases of various approaches for TLIF cage removal spanning the lumbosacral spine and recommend an operative approach based on the lumbar level, degree of subsidence, and mobility of the interbody. CONCLUSION Bilateral PTP retractors for TLIF cage removal may be effectively used in cases of pseudarthrosis with severe cage subsidence. Careful consideration of various factors, including patient surgical history, body habitus, and intraoperative findings, is essential in determining the appropriate treatment for these complex cases.
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Affiliation(s)
- S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Di M, Weng Y, Wang G, Bian H, Qi H, Wu H, Chen C, Dou Y, Wang Z, Ma X, Xu B, Zhu S, Lu WW, Yang Q. Cortical Endplate Bone Density Measured by Novel Phantomless Quantitative Computed Tomography May Predict Cage Subsidence more Conveniently and Accurately. Orthop Surg 2023; 15:3126-3135. [PMID: 37853959 PMCID: PMC10694013 DOI: 10.1111/os.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE Previous studies have shown that bone mineral density (BMD) is a predictor of cage subsidence. Phantom-less quantitative computed tomography (PL-QCT) can measure volumetric bone mineral density (vBMD) of lumbar trabecular and cortical bone. The study of endplate vBMD (EP-vBMD) is important in predicting cage settlement after extreme lateral interbody fusion (XLIF). This study aimed to determine the risk factors for postoperative cage subsidence after XLIF, particularly focusing on the relationship between vBMD measured by automatic PL-QCT and cage subsidence. METHODS Patients who underwent XLIF surgery from January 2018 to October 2020 with a minimum of 6 months of follow-up were retrospectively included. Cage subsidence was defined as >2 mm cage sinking on the adjacent endplate in follow-up imaging evaluation. Outcome measures were localized vBMDs included EP-vBMDs with different region of interest (ROI) heights measured by PL-QCT based on a customized muscle-fat algorithm. Shapiro-Wilk test, one-way ANOVA, Mann-Whitney test, Fisher exact test, univariable and multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were executed in this study. RESULTS One hundred and thirteen levels of 78 patients were included in the analysis. The mean age was 65 ± 7.9 years for 11 males and 67 females. Cage subsidence occurred on 45 (39.8%) surgical levels. There was no significant difference in demographics, fused levels, or preoperative radiographic parameters. 1.25-mm EP-vBMD (0.991 [0.985,0.997], p = 0.004) and P-TB-vBMD (cage-positioned trabecular volumetric bone mineral density) (0.988 [0.977-0.999], p = 0.026) were cage-subsidence relevant according to univariate analysis. Low 1.25-mm EP-vBMD (0.992 [0.985, 0.999], p = 0.029) was an independent risk factor according to multifactorial analysis. CONCLUSION Preoperative low EP-vBMD was an independent risk factor for postoperative cage subsidence after XLIF. EP-vBMD measured by most cortex-occupied ROI may be the optimal vBMD parameter for cage subsidence prediction.
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Affiliation(s)
- Mingyuan Di
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Yuanzhi Weng
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Guohua Wang
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Hanming Bian
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Huan Qi
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Hongjin Wu
- Graduate SchoolTianjin Medical UniversityTianjinChina
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Chao Chen
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Yiming Dou
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Zhi Wang
- Tianjin Hospital of Tianjin UniversityTianjinChina
| | - Xinlong Ma
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Baoshan Xu
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
| | - Shan Zhu
- Tianjin Hospital of Tianjin UniversityTianjinChina
| | - Weijia William Lu
- Department of Orthopaedics and TraumatologyLi Ka Shing Faculty of Medicine, The University of Hong KongPokfulamChina
- Department of Orthopaedics and TraumatologyThe University of Hong Kong‐Shenzhen HospitalShenzhenChina
| | - Qiang Yang
- Department of Spine SurgeryTianjin Hospital, Tianjin UniversityTianjinChina
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Park WT, Woo IH, Park SJ, Lee GW. Predictors of Vertebral Endplate Fractures after Oblique Lumbar Interbody Fusion. Clin Orthop Surg 2023; 15:809-817. [PMID: 37811501 PMCID: PMC10551679 DOI: 10.4055/cios23037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/25/2023] [Accepted: 03/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Cage subsidence after oblique lumbar interbody fusion (OLIF) induces restenosis and adversely affects patient outcomes. Many studies have investigated the causes of subsidence, one of which is endplate fracture (EF). This study aimed to identify predictors of EF after OLIF. Methods This retrospective study reviewed consecutive patients who underwent OLIF at a single institute between August 2019 and February 2022. A total of 104 patients were enrolled. The patients' demographic data and surgical details were collected through chart reviews. Radiographic variables were measured. Related variables were also analyzed using binomial logistic regression, dividing each group into those with versus without EF. Results EF occurred at 30 of 164 levels (18.3%), and the binary logistic analysis revealed that sex (odds ratio [OR], 11.07), inferior endplate concave depth (OR, 1.95), disc wedge angle (OR, 1.22), lumbar lordosis (OR, 1.09), pelvic incidence (OR, 1.07), sagittal vertical axis (OR, 1.02), sacral slope (OR, 0.9), L3-4 level (OR, 0.005), and L4-5 level (OR, 0.004) were significantly related to EF. Conclusions OLIF in older Asian patients should be performed carefully after recognizing the high possibility of EF and confirming the factors that should be considered preoperatively.
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Affiliation(s)
- Wook Tae Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - In Ha Woo
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Jin Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Gun Woo Lee
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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Derman PB, Yusufbekov R, Braaksma B. Device profile of the FlareHawk interbody fusion system, an endplate-conforming multi-planar expandable lumbar interbody fusion cage. Expert Rev Med Devices 2023; 20:357-364. [PMID: 37051651 DOI: 10.1080/17434440.2023.2198123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
INTRODUCTION The FlareHawk Interbody Fusion System is a family of lumbar interbody fusion devices (IBFDs) that include FlareHawk7, FlareHawk9, FlareHawk11, TiHawk7, TiHawk9, and TiHawk11. These IBFDs offer a new line of multi-planar expandable interbody devices designed to provide mechanical stability, promote arthrodesis, and allow for restoration of disc height and lordosis through a minimal insertion profile during standard open and minimally invasive posterior lumbar fusion procedures. The two-piece interbody cage design consists of a PEEK outer shell that expands in width, height, and lordosis with the insertion of a titanium shim. Once expanded, the open architecture design allows for ample graft delivery into the disc space. AREAS COVERED The design and unique features of the FlareHawk family of expandable fusion cages are described. The indications for their use are discussed. Early clinical and radiographic outcome studies using the FlareHawk Interbody Fusion System are reviewed, and properties of competitor products are outlined. EXPERT OPINION The FlareHawk multi-planar expandable interbody fusion cage is unique amongst the many lumbar fusion cages currently on the market. The multi-planar expansion, open architecture, and adaptive geometry set it apart from its competitors.
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Affiliation(s)
- Peter B Derman
- Orthopedic Spine Surgery, Texas Back Institute, Plano, TX, Unites States
| | - Rachelle Yusufbekov
- Clinical Research, Accelus, Palm Beach Gardens, FL, United States
- Johns Hopkins Whiting School of Engineering, Biomedical Engineering
| | - Brian Braaksma
- Orthopedic Spine Surgery, Texas Back Institute, Plano, TX, Unites States
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Huang Y, Chen Q, Liu L, Feng G. Vertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion. J Orthop Surg Res 2023; 18:258. [PMID: 36991489 DOI: 10.1186/s13018-023-03729-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Current evidence suggests that the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score is a good parameter for evaluating bone quality. We aimed to assess whether the VBQ score can predict the occurrence of postoperative cage subsidence after oblique lumbar interbody fusion (OLIF) surgery. METHODS Patients (n = 102) who had undergone single-level OLIF with a minimal follow-up for 1 year were reviewed in this study. Demographic and radiographic data of these patients were collected. Cage subsidence was defined as ≥ 2 mm of cage migration into the inferior endplate, superior endplate, or both. Further, the MRI-based VBQ score was measured on T1-weighted images. Moreover, univariable and multivariable binary logistic regression analyses were performed. Meanwhile, Pearson analysis was used to evaluate the correlation among the VBQ score, average lumbar dual-energy X-ray absorptiometry (DEXA) T-score, and degree of cage subsidence. Furthermore, ad-hoc analysis was used along with receiver operating characteristic curve analysis to assess the predictive ability of the VBQ score and average lumbar DEXA T-score. RESULTS Of 102 participants, cage subsidence was observed in 39 (38.24%) patients. According to the univariable analysis, patients with subsidence had older age, higher antiosteoporotic drug use, larger disk height change, a more concave morphology of inferior and superior endplates, higher VBQ score, and lower average lumbar DEXA T-score compared to patients without subsidence. In the multivariable logistic regression analysis, a higher VBQ score was significantly associated with an increased risk of subsidence (OR = 23.158 ± 0.849, 95% CI 4.381-122.399, p < 0.001), and it was the only significant and independent predictor of subsidence after OLIF. Moreover, the VBQ score was moderately correlated with the average lumbar DEXA T-score (r = - 0.576, p < 0.001) and the amount of cage subsidence (r = 0.649, p < 0.001). Furthermore, this score significantly predicted cage subsidence with an accuracy of 83.9%. CONCLUSIONS The VBQ score can independently predict postoperative cage subsidence in patients undergoing OLIF surgery.
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Affiliation(s)
- Yong Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Qian Chen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Department of Orthopaedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Limin Liu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Ganjun Feng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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