Tag: Fusion rate

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Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up

The Spine Journal 23 (2023) 1494−1505

Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches.

PURPOSE: To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery.

DESIGN: Prospective, multicenter, international, observational cohort study.

PATIENT SAMPLE: Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion.

OUTCOME MEASURES: Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. METHODS: Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison.

RESULTS: Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 § 21.3 vs 25.8 § 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390).

CONCLUSIONS: Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

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What Is the Fate of Pseudarthrosis Detected 1 Year After Anterior Cervical Discectomy and Fusion?

Spine 2018;43:E23–E28

Objective. To investigate the consequences and appropriate management of pseudarthrosis after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data. Pseudarthrosis is a frequent complication of ACDF and causes unsatisfactory results. Little is known about long-term prognosis of detecting pseudarthrosis 1 year after ACDF.

Methods. Eighty-nine patients with a minimum 2-year followup were included. ACDF surgery using allograft and plating was performed: single-level in 51 patients, two-level in 26 patients, and three-level in 12 patients. Presence of pseudarthrosis was evaluated 1 year postoperatively and then the nonunion segments were re-evaluated 2 years postoperatively. Demographic data were assessed to identify the risk factors associated with pseudarthrosis. A visual analogue scale for neck/arm pain and the Neck Disability Index were analyzed preoperatively and at 1 and 2 years postoperatively.

Results. Pseudarthrosis was detected in 29 patients (32.6%) 1 year postoperatively: 15of 51 patients after single-level surgery, 9 of 26 patients after two-level surgery, and 5 of 12 patients after three-level surgery. Only eight patients showed persistent nonunion at 2 years: 3 of 15 patients after single-level surgery, 3 of 9 after two-level surgery, and 2 of 5 after three-level surgery. The remaining 21 patients (72.4%) achieved bony fusion 2 years postoperatively without any intervention. Patients who underwent two-level or three-level ACDF had a significantly higher pseudarthrosis rate than those who underwent single-level ACDF, with odds ratios of 1.844 and 3.147, respectively. The improvements in visual analogue scale for neck pain and Neck Disability Index scores in the persistent nonunion group were significantly lower than those in the final union group at 2 years.

Conclusion. Patients with pseudarthrosis detected 1 year postoperatively may be observed without any intervention because approximately 70% of them will eventually fuse by the 2-year point. Early revision could, however, be considered if the pseudarthrosis is associated with considerable neck pain after multilevel ACDF.

Level of Evidence: 3

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Extension CT scan: its suitability for assessing fusion after posterior lumbar interbody fusion

Eur Spine J (2011) 20:1496–1502. DOI 10.1007/s00586-011-1739-0

Posterior lumbar interbody fusion (PLIF) is a popular procedure for treating lumbar canal stenosis with spinal instability, and several reports concerning fusion assessment methods exist. However, there are currently no definitive criteria for diagnosing a successful interbody fusion in the lumbar spine. We suggested evaluating fusion status using computed tomography (CT) in extension position to detect pseudoarthrosis more precisely.

The purpose of this study was to evaluate its usefulness for determining bone union quality after PLIF.

Eighty-one patients who underwent PLIF at 97 levels were retrospectively enrolled. The study population included 48 men and 33 women (mean age 58.9 years, range 21–85 years). Patients were followed up for more than 12 months after surgery. The mean follow-up period was 27.6 months (range 14–49 months). Fusion status was evaluated using three ways: flexion– extension radiographs, CT images in flexion and extension position. In the flexion–extension radiographs, mobility of more than 3 , a remaining clear zone, or an uncertain bone connection constituted an incomplete union. For CT images, a remaining clear zone, a gas pattern, or an uncertain bone connection constituted an incomplete union.

Flexion– extension radiographs demonstrated a solid fusion in 90.7% of the 97 levels at 10.7 months postoperatively. When fusion was demonstrated on flexion–extension radiographs, the rate of fusion affirmed by flexion CT and extension CT was 87.6 and 69.1% of the levels assessed, respectively. The rate of pseudoarthrosis detected on extension CT images was significantly higher than that on flexion–extension radiographs (P< 0.001) and flexion CT (P< 0.01). The rate of fusion achieved on extension CT was 85.6% at 15.1 months postoperatively.

Extension CT could detect pseudoarthrosis more clearly than flexion–extension radiography and flexion CT. The CT images are influenced by body position and dilating anterior disc space in extension CT contributes to detect pseudoarthrodesis. Thus, extension CT was a useful method for assessing fusion status after PLIF.

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