Single position lumbar fusion: a systematic review and meta-analysis

The Spine Journal 22 (2022) 429−443

Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position.

PURPOSE: The purpose of this study was to present and analyze the current evidence for single position lumbar fusion.

STUDY DESIGN/SETTING: This is a systematic review and meta-analysis.

PATIENT SAMPLE: Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included.

OUTCOME MEASURES: Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis.

METHODS: This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05.

RESULTS: Twenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5§7.9, F: 188.7§15.5, p<.001). Average hospital length of stay was 2.87§0.3 days in the SP group and 6.63§0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2§2%, P: 1.6§1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1§5.5 minutes vs. 166.9§21.9 minutes, p<.001; 43.7§15.5 minutes vs. 171.0§25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001).

CONCLUSIONS: Single position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.