Tag: Spine fusion

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Adjacent segment disease treated with stand-alone lateral lumbar interbody fusion: an analysis of domino adjacent segment revisions

J Neurosurg Spine 44:884–893, 2026

This clinical study compares stand-alone lateral lumbar interbody fusion (LLIF) with circumferential LLIF plus posterior instrumentation for treating adjacent segment disease (ASD) after prior posterior lumbosacral fusion. Primary outcome focused on “domino” proximal ASD revisions, with secondary measures including cage subsidence, radiographic alignment, and perioperative metrics.

Results from 236 patients show stand-alone LLIF had significantly lower 5-year domino ASD revision rates, shorter operative times and hospital stays, and comparable alignment despite higher rates of moderate-to-severe cage subsidence. Multivariable and competing-risk analyses supported stand-alone LLIF’s protective association against subsequent adjacent-segment reoperations.

Objective Assess whether stand-alone LLIF is a durable ASD revision strategy with lower risk of subsequent “domino” adjacent-segment revision compared with circumferential LLIF (LLIF + posterior fusion extension).

Design/Methods Single-center retrospective cohort (Jan 2008–Aug 2023) of patients with prior posterior lumbosacral fusion undergoing ASD revision via stand-alone vs circumferential LLIF; primary outcome was domino ASD revision; survival analysis and multivariable Cox regression used, adjusting for alignment, stenosis severity, and fused levels.

Cohort 236 patients included (131 stand-alone; 105 circumferential); baseline demographics/treated levels similar; preop MRI showed more severe central stenosis in the circumferential group (more Schizas grade D).

Primary outcome Stand-alone LLIF had a lower 5-year incidence of domino ASD revision (13.7% vs 28.6%, p = 0.005).

Adjusted association After multivariable adjustment, stand-alone LLIF remained independently associated with fewer domino ASD revisions (HR 0.43, 95% CI 0.23–0.79; p = 0.007).

Radiographic outcomes Overall radiographic alignment was comparable between groups, but stand-alone LLIF had higher cage subsidence (Marchi grade ≥ II: 22.9% vs 9.5%, p = 0.019), and subsidence was not associated with increased revision risk.

Perioperative outcomes Stand-alone LLIF had significantly shorter operative time and hospital stay than circumferential LLIF (with lower blood loss also reported).

Conclusion Stand-alone LLIF is supported as a treatment option for ASD after prior posterior fusion, with less domino ASD revision and similar radiographic alignment, at the cost of higher subsidence rates.

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To fuse or not to fuse: surgical strategies for recurrent lumbar disc herniation from a 16-nation study

J Neurosurg Spine 43:681–692, 2025

This international survey examines variability in surgical management of recurrent lumbar disc herniation across 515 spine surgeons from 16 countries, comparing redo discectomy versus various fusion techniques for six clinical scenarios. Findings reveal substantial inter- and intranational differences, specialty-related tendencies, and consensus only for simple first recurrences without back pain.

The study identifies key decision drivers—lumbar pain with radiculopathy and inflammatory disc disease—highlights gaps in high-level evidence, and calls for standardized research, registries, and improved training to harmonize indications and reduce practice heterogeneity.

Significant International Variability: Surgical strategies for recurrent lumbar disc herniation (LDH) vary widely among spine surgeons internationally, especially beyond the first recurrence without low back pain or instability, where decisions are more homogeneous.

Decision-Making Factors: Key factors influencing the choice for fusion over redo discectomy include the presence of low back pain with radiculopathy, radiological evidence of inflammatory disc disease, and the occurrence of second recurrences.

Surgeon Specialty Impact: Orthopedic surgeons are significantly more likely to propose procedures involving implants (fusion) compared to neurosurgeons, regardless of other demographic factors.

Country-Specific Patterns: Countries with low variability (e.g., Portugal, China, UK, Germany) favor posterior lumbar interbody fusion (PLIF/TLIF) and redo discectomy, while countries with high variability (e.g., France, Tunisia, US, Brazil) show more diverse approaches, including anterior and combined procedures.

Limited Influence of Experience and Practice Type: Duration of practice, annual surgical volume, and type of institution (public vs. private) generally do not significantly affect procedure choice, except in some first recurrence cases where public practitioners favor redo discectomy.

Lack of High-Level Evidence: There is a lack of strong, consistent evidence or guidelines favoring one surgical approach over another for recurrent LDH, contributing to the observed variability.

Patient and Surgeon Preferences: Decision-making is influenced by patient preferences, surgeon familiarity with techniques, desire for low-morbidity procedures, and adherence to literature, though economic factors play a lesser role.

Call for Standardization and Research: The findings highlight the need for high-quality studies, improved training, and international collaboration to reduce variability and improve decision-making in recurrent LDH surgery.

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Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis

J Neurosurg Spine 40:45–53, 2024

Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population.

METHODS A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication.

RESULTS Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36–5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28–0.49 vs OR 0.32, 95% CI 0.22–0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52–0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23–1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001).

CONCLUSIONS Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.

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Cost Utility Analysis of the Cervical Artificial Disc vs Fusion for the Treatment of 2-Level Symptomatic Degenerative Disc Disease: 5-Year Follow-up

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Neurosurgery 79:135–145, 2016

The cervical total disc replacement (cTDR) was developed to treat cervical degenerative disc disease while preserving motion.

OBJECTIVE: Cost-effectiveness of this intervention was established by looking at 2-year follow-up, and this update reevaluates our analysis over 5 years.

METHODS: Data were derived from a randomized trial of 330 patients. Data from the 12- Item Short Form Health Survey were transformed into utilities by using the SF-6D algorithm. Costs were calculated by extracting diagnosis-related group codes and then applying 2014 Medicare reimbursement rates. A Markov model evaluated qualityadjusted life years (QALYs) for both treatment groups. Univariate and multivariate sensitivity analyses were conducted to test the stability of the model. The model adopted both societal and health system perspectives and applied a 3% annual discount rate.

RESULTS: The cTDR costs $1687 more than anterior cervical discectomy and fusion (ACDF) over 5 years. In contrast, cTDR had $34 377 less productivity loss compared with ACDF. There was a significant difference in the return-to-work rate (81.6% compared with 65.4% for cTDR and ACDF, respectively; P = .029). From a societal perspective, the incremental cost-effective ratio (ICER) for cTDR was 2$165 103 per QALY. From a health system perspective, the ICER for cTDR was $8518 per QALY. In the sensitivity analysis, the ICER for cTDR remained below the US willingness-to-pay threshold of $50 000 per QALY in all scenarios (2$225 816 per QALY to $22 071 per QALY).

CONCLUSION: This study is the first to report the comparative cost-effectiveness of cTDR vs ACDF for 2-level degenerative disc disease at 5 years. The authors conclude that, because of the negative ICER, cTDR is the dominant modality.

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