Tag: interbody fusion

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Outcomes After Decompression Only Versus Decompression and Fusion for Lumbar Facet Cysts: A Systematic Review and Meta-Analysis

Neurosurgery 97:536–544, 2025

This meta-analysis compared decompression only (DO) versus decompression and fusion (DF) for lumbar facet cysts. DF reduced cyst recurrence and improved back pain resolution but had longer hospital stays. Reoperation and radiculopathy resolution rates were similar between groups. Most studies lacked standardized criteria for choosing DF over DO.

• Lumbar facet cysts (LFCs) are associated with facet degeneration and segmental instability; surgical management is debated between decompression only (DO) and decompression with fusion (DF).

• This systematic review and meta-analysis included 9 comparative studies with 3393 patients (DO: 1940, DF: 1453).

• Spondylolisthesis rates were significantly higher in the DF group (65.8% vs 24.3% in DO).

• DO had higher odds of cyst recurrence (6.3% vs 0%) and lower odds of back pain resolution (56.6% vs 74.5%) compared to DF.

• Reoperation rates (DO 7.2%, DF 5.9%) and radiculopathy resolution (DO 77.3%, DF 87.2%) were similar between groups.

• Length of hospital stay was shorter in the DO group.

• Criteria for choosing DF vs DO varied and were often not clearly defined across studies.

• The study concludes DF reduces cyst recurrence and improves back pain resolution but has longer hospital stays; reoperation and radiculopathy outcomes are comparable.

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Modic Changes Increase the Cage Subsidence Rate in Spinal Interbody Fusion Surgery: A Systematic Review and Network Meta-Analysis

OBJECTIVE: To compare the effect of different Modic changes (MC) grades on the cage subsidence rate after spinal interbody fusion surgery.

METHODS: We comprehensively searched the PubMed, Embase, and Web of Science databases from inception to August 13, 2023, for relevant randomized controlled trials and prospective and retrospective cohort studies. Review Manager 5.3 and STATA13.0 were used to conduct this meta-analysis. The subsidence rate was assessed using relative risk and 95% confidence intervals.

RESULTS: Six studies with a total of 716 segments were allocated to four groups according to the type of MC. The subsidence rate in the non-Modic changes (NMC) was significantly lower than that in the MC. The subsidence rate in the NMC was significantly lower than that in the MC in the subgroup of cages with extra instrumentation. No significant difference was identified between the 2 groups in the oblique lumbar interbody fusion subgroup. The subsidence rate in the NMC was significantly lower than that in the MC in the transforaminal lumbar interbody fusion subgroup. The subsidence rate in the NMC was significantly lower than that in the MC1 and MC2. We found no significant difference between NMC and MC3, MC1 and MC2, MC1 and MC3, or MC2 and MC3.

CONCLUSIONS: MC may be associated with a higher cage subsidence rate. With the increase in MC grades, the incidence of subsidence decreased gradually, but it was always higher than that in the NMC. Oblique lumbar interbody fusion may be a better choice for the treatment of lumbar degenerative disease with MC.

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Risk Factors for Adjacent Segment Disease in Short Segment Lumbar Interbody Fusion

Operative Neurosurgery 25:136–141, 2023

Adjacent segment disease (ASD) is a common problem after lumbar spinal fusions. Ways to reduce the rates of ASD are highly sought after to reduce the need for reoperation.

OBJECTIVE: To find predisposing factors of ASD after lumbar interbody fusions, especially in mismatch of pelvic incidence and lumbar lordosis (PI-LL).

METHODS: We conducted a retrospective cohort study of all patients undergoing lumbar interbody fusions of less than 4 levels from June 2015 to July 2020 with at least 1 year of follow-up and in those who had obtained postoperative standing X-rays.

RESULTS: We found 243 patients who fit inclusion and exclusion criteria. Fourteen patients (5.8%) developed ASD, at a median of 24 months. Postoperative lumbar lordosis was significantly higher in the non-ASD cohort (median 46.4°± 1.4°vs 36.9°± 3.6°, P < .001), pelvic tilt was significantly lower in the non-ASD cohort (16.0°± 0.66°vs 20.3°± 2.4°, P = .002), PI-LL mismatch was significantly lower in the non-ASD cohort (5.28°± 1.0°vs 17.1°± 2.0°, P < .001), and age-appropriate PI-LL mismatch was less common in the non-ASD cohort (34 patients [14.8%] vs 13 [92.9%] of patients with high mismatch, P < .001). Using multivariate analysis, greater PI-LL mismatch was predictive of ASD (95% odds ratio CI = 1.393-2.458, P < .001) and age-appropriate PI-LL mismatch was predictive of ASD (95% odds ratio CI = 10.8-970.4, P < .001).

CONCLUSION: Higher PI-LL mismatch, both age-independent and when adjusted for age, after lumbar interbody fusion was predictive for developing ASD. In lumbar degenerative disease, correction of spinopelvic parameters should be a main goal of surgical correction.

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Anterior-To-Psoas Approach Measurements, Feasibility, Non-Neurological Structures at Risk and Influencing Factors: A Bilateral Analysis From L1-L5 Using Computed Tomography Imaging

Operative Neurosurgery 25:52–58, 2023

Spinal fusion through the anterior-to-psoas (ATP) technique harbors several approach-related risks. We used abdominal computed tomography imaging to analyze the L1-L5 ATP fusion approach measurements, feasibility, degree of obstruction by non-neurological structures, and the influence of patient characteristics on ATP approach dimensions.

METHODS: The vascular window, psoas window, safe window, and incision line anterior and posterior margins for the ATP approach were measured on abdominal computed tomography imaging. The feasibility of approach and the presence of kidneys, ribs, liver, spleen, and iliac crests within the ATP approach were also measured. Correlation and regression models among radiographic measurements and patient age, height, weight, and body mass index (BMI) were analyzed as well as differences in approach measurements based on sex.

RESULTS: Safe window and incision line measurements were more accommodating for the left-sided vs right-sided ATP approach. At L4-5, the ATP approach was not feasible 18% of the time on the left side vs 60% of the time on the right side. The spleen was present 22%, 10%, and 3% of the time from L1-4, while the liver was present 56%, 30%, and 9% of the time. The iliac crests were not observed within ATP parameters. Patient age, height, weight, and BMI did not strongly correlate with approach measurements, although ATP dimensions did differ based on sex.

CONCLUSION: This study reports characteristics of the ATP approach including approach measurements, feasibility, non-neurological structures at risk, and influencing factors to approach measurements. While incision line measurements are larger for male patients compared with female patients at the lower lumbar levels, safe window sizes are similar across all levels L1-L5. The kidneys, ribs, spleen, and liver are potential at-risk structures during the ATP approach, although the iliac crests pose limited concern for ATP technique. Patient characteristics such as age, height, weight, and BMI do not markedly affect ATP approach considerations.

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Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis

Neurosurgery 93:186–197, 2023

Transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone are two operations performed to treat degenerative lumbar spondylolisthesis. To date, it is unclear which operation leads to better outcomes.

OBJECTIVE: To compare TLIF vs PLF alone regarding long-term reoperation rates, complications, and patient-reported outcome measures (PROMs) in patients with degenerative grade 1 spondylolisthesis.

METHODS: A retrospective cohort study using prospectively collected data between October 2010 and May 2021 was undertaken. Inclusion criteria were patients aged 18 years or older with grade 1 degenerative spondylolisthesis undergoing elective, single-level, open posterior lumbar decompression and instrumented fusion with ≥1-year follow-up. The primary exposure was presence of TLIF vs PLF without interbody fusion. The primary outcome was reoperation. Secondary outcomes included complications, readmission, discharge disposition, return to work, and PROMs at 3 and 12 months postoperatively, including Numeric Rating Scale-Back/Leg and Oswestry Disability Index. Minimum clinically important difference of PROMs was set at 30% improvement from baseline.

RESULTS: Of 546 patients, 373 (68.3%) underwent TLIF and 173 underwent (31.7%) PLF. Median follow-up was 6.1 years (IQR = 3.6-9.0), with 339 (62.1%) >5-year follow-up. Multivariable logistic regression showed that patients undergoing TLIF had a lower odds of reoperation compared with PLF alone (odds ratio = 0.23, 95% CI = 0.54-0.99, P = .048). Among patients with >5-year follow-up, the same trend was seen (odds ratio = 0.15, 95% CI = 0.03-0.95, P = .045). No differences were observed in 90-day complications (P = .487) and readmission rates (P = .230) or minimum clinically important difference PROMs.

CONCLUSION: In a retrospective cohort study from a prospectively maintained registry, patients with grade 1 degenerative spondylolisthesis undergoing TLIF had significantly lower long-term reoperation rates than those undergoing PLF.

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Minimally invasive lateral fusion for adjacent disease

Minimally invasive lateral interbody fusion for the treatment of rostral adjacent-segment lumbar degenerative stenosis without supplemental pedicle screw fixation

J Neurosurg Spine 21:861–866, 2014

Adjacent-segment degeneration and stenosis are common in patients who have undergone previous lumbar fusion. Treatment typically involves a revision posterior approach, which requires management of postoperative scar tissue and previously implanted instrumentation. A minimally invasive lateral approach allows the surgeon to potentially reduce the risk of these hazards. The technique relies on indirect decompression to treat central and foraminal stenosis and placement of a graft with a large surface area to promote robust fusion and stability in concert with the surrounding tensioned ligaments. The goal in this study was to determine if lateral interbody fusion without supplemental pedicle screws is effective in treating adjacent-segment disease.

Methods. For a 30-month study period at two institutions, the authors obtained all cases of lumbar fusion with new back and leg pain due to adjacent-segment stenosis and spondylosis failing conservative measures. All patients had undergone minimally invasive lateral interbody fusion from the side of greater leg pain without supplemental pedicle screw fixation. Patients were excluded from the study if they had undergone surgery for a nondegenerative etiology such as infection or trauma. They were also excluded if the intervention involved supplemental posterior instrumented fusion with transpedicular screws. Postoperative metrics included numeric pain scale (NPS) scores for leg and back pain. All patients underwent dynamic radiographs and CT scanning to assess stability and fusion after surgery.

Results. During the 30-month study period, 21 patients (43% female) were successfully treated using minimally invasive lateral interbody fusion without the need for subsequent posterior transpedicular fixation. The mean patient age was 61 years (range 37–87 years). Four patients had two adjacent levels fused, while the remainder had single-level surgery. All patients underwent surgery without conversion to a traditional open technique, and recombinant human bone morphogenetic protein–2 was used in the interbody space in all cases. The mean follow-up was 23.6 months. The mean operative time was 86 minutes, and the mean blood loss was 93 ml. There were no major intraoperative complications, but one patient underwent subsequent direct decompression in a delayed fashion. The leg pain NPS score improved from a mean of 6.3 to 1.9 (p < 0.01), and the back pain NPS score improved from a mean of 7.5 to 2.9 (p < 0.01). Intervertebral settling averaged 1.7 mm. All patients had bridging bone on CT scanning at the last follow-up, indicating solid bony fusion.

Conclusions. Adjacent-segment stenosis and spondylosis can be treated with a number of different operative techniques. Lateral interbody fusion provides an attractive alternative with reduced blood loss and complications, as there is no need to re-explore a previous laminectomy site. In this limited series a minimally invasive lateral approach provided high fusion rates when performed with osteobiological adjuvants.

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Results and complications after 2-level axial lumbar interbody fusion with a minimum 2-year follow-up

J Neurosurg: Spine / July 17, 2012. DOI: 10.3171/2012.6.SPINE11915

Axial lumbar interbody fusion (AxiaLIF) is a minimally invasive presacral surgical technique that damages neither the anulus fibrosus nor the anterior or posterior longitudinal ligaments. The technique was initially designed and used for L5–S1 interbody fusions and recently was extended to 2-level fusions (L4–5 and L5–S1). Until now, only biomechanical and radiological studies have discussed the feasibility of this new indication, and no clinical study has been published. The purpose of this article is to report results and complications associated with 2-level presacral AxiaLIF with a minimum of 24 months of follow-up.

METHODS
In this prospective, nonrandomized, single-center study, 27 patients underwent presacral AxiaLIF surgery at the L4–5 and L5–S1 levels. Clinical outcomes were assessed using the visual analog scale for back and leg symptoms and the Oswestry Disability Index. Radiographic parameters, such as disc height, segmental lordosis, and bone fusion, were analyzed using radiographs and CT scans. Complications and revision surgeries were recorded as needed. The minimum follow-up was 24 months (up to 72 months).

RESULTS
There were no intraoperative complications. One major complication was observed: a patient developed septicemia that resolved after proper care. Clinical outcomes scores showed overall improvement in pain and physical function. During follow-up, the following complications were observed in the construct: screw breakage (14.8%), proximal/distal transsacral rod detachment (11.1%), radiolucency around the transsacral rod (52%), and cephalic rod migration (24%). Disc height gain was reported early after surgery, but at the 24-month follow-up the disc space was diminished in comparison with the preoperative status. Compared with preoperative values, the 24-month results showed loss of segmental lordosis. Only 22% of all treated levels were considered to have solid fusion at the 24-month radiological evaluation.

CONCLUSIONS
Patients undergoing presacral 2-level AxiaLIF experienced satisfactory short-term clinical outcomes; however, complications were commonly seen on imaging studies obtained 24 months postoperatively. Additional studies are required to better understand the 2-level indications for this technique.

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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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Minimally invasive extracavitary approach for thoracic discectomy and interbody fusion: 1-year clinical and radiographic outcomes in 13 patients compared with a cohort of traditional anterior transthoracic approaches

J Neurosurg Spine 14:250–260, 2011.DOI: 10.3171/2010.10.SPINE09456

Open transthoracic approaches, considered the standard in treating thoracic disc herniation (TDH), are associated with significant comorbidities. The authors describe a minimally invasive lateral extracavitary tubular approach for discectomy and fusion (MIECTDF) to treat TDH.

Methods. In 13 patients (5 men, 8 women; mean age 51.8 years) with myelopathy and 15 noncalcified TDHs, the authors achieved a far-lateral trajectory by dilating percutaneously to a 20-mm working portal docked at the transverse process–facet junction, which then provided a corridor for a near-total discectomy, bilateral laminotomies, and interbody arthrodesis requiring minimal cord retraction. A cohort of 11 demographically comparable patients treated via transthoracic approaches was used as control.

Results. Preoperative Frankel grades were B in 1 patient, C in 4, D in 5, and E in 3, whereas at mean of 10 months, 11 had Grade E function and 2 had Grade D function. Mean surgical metrics were operating room time 93.75 minutes, blood loss 33 ml, and hospital stay 3.1 days. Complications included 4 transient paresthesias, 1 CSF leak, 1 abdominal wall weakness, and 3 nonwound infections. One-year follow-up MR imaging revealed full decompression in all cases and no cage migration. Mean visual analog scales scores preoperative, at 6 weeks, 3 months, and 1 year were 5.6, 4.5, 3.2, and 1.2, respectively. No differences existed in preoperative clinical and radiographic profile of the study and control groups. Compared with controls, the MIECTDF group achieved superior scores in all metrics (p < 0.01) except for equivalent 1-year neurological outcomes.

Conclusions. Compared with transthoracic procedures, MIECTDF effectively decompressed the spinal canal, yielding identical 1-year radiographic and clinical outcomes to those seen in controls, while producing superior clinical scores in the interim. Thus, MIECTDF is the authors’ treatment of choice for TDH.

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Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine

Eur Spine J. DOI 10.1007/s00586-010-1578-4

Minimally invasive lumbar fusion techniques have been developed in recent 20 years. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain, and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of minimally invasive transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression or a traditional open approach.

A prospective clinical study was performed by evaluating the clinical and radiographic results of minimally invasive transforaminal lumbar interbody fusion as an alternative new technique in the revision surgery for patients previously treated by open procedure. 52 patients (28 M, 24 F) with an average age of 55.7 (31–76) were prospectively evaluated. All patients who had previous discectomy (n = 13), hemilaminectomy (n = 16), laminectomy (n = 12) and facetectomy (n = 11) underwent monosegmental and bisegmental minimally invasive transforaminal lumbar interbody fusion (MiTLIF) (n = 25) or open transforaminal lumbar interbody fusion (OTLIF) (n = 27) by two experienced surgeons at one hospital, from March 2006 to October 2008 (minimum 12-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, X-ray exposure time, postoperative back pain, and complications. Clinical outcome was assessed using the visual analogue scale and the Oswestry disability index (ODI). The operative time and clinical and radiographic results were basically identical in both groups.

Comparing with the OTLIF group, the MiTLIF group had significantly less blood loss and less postoperative back pain at the second day postoperatively. The radiation time was significantly longer in the MiTLIF group. Complications included three cases of small dural tear in the MiTLIF group. There were five cases of dural tear and two cases of superficial wound infection in the OTLIF group. One case of nonunion was observed from each group.

Minimally invasive TLIF is a safe and effective procedure for treatment of selected revision patients previously treated by open surgery with some potential advantages. However, this technique needs longer X-ray exposure time.

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