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Lin GX, He LR, Nan JN, Xu WB, Xiao K, Que Z, Jhang SW, Chen CM, Zhu MT, Rui G. Comparing Outcomes of Banana-Shaped and Straight Cages in Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis. Neurospine 2024; 21:261-272. [PMID: 38317558 PMCID: PMC10992667 DOI: 10.14245/ns.2347078.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE This meta-analysis aims to refine the understanding of the optimal choice between different cage shapes in transforaminal lumbar interbody fusion (TLIF) by systematically comparing perioperative data, radiological outcomes, clinical results, and complications associated with banana-shaped and straight bullet cages. METHODS A meticulous literature search encompassing PubMed, Embase, Scopus, Web of Science, China Knowledge Network, and Wanfang Data was executed up to October 5, 2023. Inclusion criteria focused on studies comparing banana-shaped and straight bullet cages in TLIF. The quality of included studies was assessed using appropriate tools such as the Newcastle-Ottawa Scale (NOS) for nonrandomized studies. Rigorous evaluations were performed for radiographic outcomes, including disc height (DH), segmental lordosis (SL), lumbar lordosis (LL), subsidence, and fusion rates. Clinical outcomes were meticulously evaluated using visual analogue scale (VAS), Oswestry Disability Index (ODI), and complications. RESULTS The analysis incorporated 7 studies, involving 573 patients (297 with banana-shaped cages, 276 with straight cages), all with NOS ratings exceeding 5 stars. No statistically significant differences were observed in operative time, blood loss, or hospitalization between the 2 cage shapes. Banana-shaped cages exhibited greater changes in DH (p = 0.001), SL (p = 0.02), and LL (p = 0.01). Despite statistically higher changes in ODI for straight cages (26.33, p < 0.0001), the actual value remained similar to banana-shaped cages (26.15). Both cage types demonstrated similar efficacy in VAS, complication rates, subsidence, and fusion rates. CONCLUSION Although banana-shaped cages can excel in restoring DH, SL, and LL, straight bullet cages can provide comparable functional improvements, pain relief, and complication rates.
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Affiliation(s)
- Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Li-Ru He
- Department of Anesthesia and Surgery, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Jin-Niang Nan
- Department of Clinical Medicine, Nanchang Medical College, Nanchang, China
| | - Wen-Bin Xu
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Keyi Xiao
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Zhiqiang Que
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Shang-Wun Jhang
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan
- Department of Biomedical Sciences National Chung Cheng University, Chiayi, Taiwan
| | - Ming-Tao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Gang Rui
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
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Levy AS, Maddy K, Murray A, John DL, Kumar V, Urakov T. Transforaminal lumbar interbody fusion with placement of steerable banana cage: A single-center retrospective analysis of radiographic parameters of success. Radiography (Lond) 2024; 30:163-167. [PMID: 38035428 DOI: 10.1016/j.radi.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION The transforaminal lumbar interbody fusion (TLIF) is among the most utilized methods for the surgical treatment of lumbar degenerative disc disease. The TLIF has advanced significantly with several iterative changes since its inception in the early 1980s, with the advent of several generations of interbody types, shapes, and materials. Steerable curvilinear interbodies are among the most recent innovations in this space and may offer biomechanical advantages, namely in preservation of lumbar and segmental lordosis. While radiographic parameters have been investigated for other cage shapes and lumbar interbody fusion techniques, no study has investigated postoperative radiographic outcomes specific to TLIFs done with curvilinear interbodies. METHODS This study is a retrospective review of TLIFs performed with curvilinear interbodies between 2019 and 2022 at a single institution. Upright radiographs were obtained preoperatively and at several timepoints postoperatively. Radiographic variables including interspace height and segmental lordosis were collected. RESULTS 26 surgeries with 32 curvilinear interbodies were performed across 3 years. There was significant increase in segmental lordosis at the L4-L5 (p = 0.0183) and L5-S1 levels (p = 0.004) as well as interspace height postoperatively at levels L3-L4 (p = 0.011) and L4-L5 (p = 0.002). Pain as measured with the numeric rating scale significantly improved in the overall cohort postoperatively (p<0.001). CONCLUSIONS TLIF with curvilinear interbody placement increases segmental lordosis and interspace height at the L4-L5 and L5-S1 levels, and increased interspace height at the L3-L4 and L4-L5 levels. Further investigation into additional radiographic parameters is warranted and expanded cohort size would benefit deeper analysis of other spinal levels. IMPLICATIONS FOR PRACTICE As an increasing number of cage designs and materials are brought to market, studies such as this allow for better understanding of cage specific outcomes allowing for better informed device selection.
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Affiliation(s)
- A S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - K Maddy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - A Murray
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - D L John
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - V Kumar
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - T Urakov
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
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Lee S, Kim JG, Kim HJ. Comparison of surgical outcomes between lumbar interbody fusions using expandable and static cages: a systematic review and meta-analysis. Spine J 2023; 23:1593-1601. [PMID: 37473812 DOI: 10.1016/j.spinee.2023.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/07/2023] [Accepted: 07/16/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The use of static cages for lumbar interbody fusion (LIF) can cause complications such as end plate violation, graft subsidence, and nerve injury. Therefore, expandable cages that allow for in-situ expansion have been developed to overcome these problems. However, it remains uncertain whether expandable cages have better surgical outcomes than static cages do. PURPOSE We aimed to determine the effectiveness of expandable cages by analyzing studies that compared the surgical outcomes between the use of expandable cages and static cages. STUDY DESIGN A systematic review and meta-analysis. METHODS The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to conduct this meta-analysis and systematic review. The primary outcomes of this study were anterior disc height, posterior disc height, segmental lordosis (SL), lumbar lordosis (LL), subsidence rate, numeric rating scale (NRS) scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS Thirteen studies with 1,700 patients were included in the meta-analysis. Compared with static cages for LIFs, expandable cages significantly increased the anterior disc height (standardized mean difference 0.478, 95% confidence interval [CI] 0.088-0.867, p=.0162) and segmental lordosis (sMD 0.307, 95% CI 0.159-0.454, p<.0001). There were no significant differences in the posterior disc height, lumbar lordosis, subsidence rate, back pain, leg pain, or ODI between the two groups. CONCLUSION Expandable cages show no clear clinical benefit over static cages.
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Affiliation(s)
- Sanghoon Lee
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Jung Guel Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea.
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Su YH, Wu PK, Wu MH, Wong KW, Li WW, Chou SH. Comparison of the Radiographic and Clinical Outcomes Between Expandable Cage and Static Cage for Transforaminal Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 179:133-142. [PMID: 37579991 DOI: 10.1016/j.wneu.2023.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Yu-Hsiang Su
- Department of Education, China Medical University Hospital, Taichung, Taiwan
| | - Po-Kuan Wu
- Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan
| | - Meng-Huang Wu
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; TMU Biodesign Center, Taipei Medical University, Taipei, Taiwan; Department of Orthopaedics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kin-Weng Wong
- Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Wei Li
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shih-Hsiang Chou
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Departments of Orthopedics, School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Sebaaly A, Kreichati G, Tarchichi J, Kharrat K, Daher M. Transforaminal lumbar interbody fusion using banana-shaped and straight cages: meta-analysis of clinical and radiological outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3158-3166. [PMID: 37326836 DOI: 10.1007/s00586-023-07797-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE Transforaminal lumbar interbody fusion (TLIF) surgery rate increased over the last decade. There is no consensus about the better shape of cage to use in TLIF. This meta-analysis was conducted to compare the shape focusing on bony union, lordosis restoration as well as perioperative complications. METHODS PubMed, Cochrane, and Google Scholar (page 1-20) were searched till September 2022. The clinical outcomes consisted of the bony union, segmental and lumbar lordosis restoration, quality of life, and operation-related outcomes. RESULTS Only 5 studies were included in this meta-analysis. Straight-shaped cages tended to have a lower subsidence rate compared to banana-shaped cages (p = 0.10), had a better restoration of segmental lordosis (p < 0.0001), better disc height restoration (p = 0.01), as well as a higher Oswestry Disability Index decrease (p = 0.0002). CONCLUSION Straight-shaped cages had a better restoration of lumbar lordosis, disc height, and a lower subsidence rate when compared to banana-shaped cages. This may be explained by the absence of the optimal placement of the curved cages, which is at the most anterior part of the disc space. Better conducted randomized controlled trial could strengthen these findings.
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Affiliation(s)
- Amer Sebaaly
- Department of Orthopedic Surgery Spine Unit, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon.
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
| | - Gaby Kreichati
- Department of Orthopedic Surgery Spine Unit, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Jean Tarchichi
- Department of Orthopedic Surgery Spine Unit, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopedic Surgery Spine Unit, Hotel Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Mohammad Daher
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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Ledesma JA, Ottaway JC, Lambrechts MJ, Dees A, Thomas TL, Kurd MF, Radcliff KE, Anderson DG. Early Experience With Uniplanar Versus Biplanar Expandable Interbody Fusion Devices in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion. Neurospine 2023; 20:487-497. [PMID: 37401067 PMCID: PMC10323343 DOI: 10.14245/ns.2244870.435] [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] [Received: 09/29/2022] [Revised: 01/20/2023] [Accepted: 02/17/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE To compare the early radiographic and clinical outcomes of expandable uniplanar versus biplanar interbody cages used for single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS A retrospective review of 1-level MIS-TLIFs performed with uniplanar and biplanar polyetheretherketone cages was performed. Radiographic measurements were performed on radiographs taken preoperatively, at 6-week follow-up, and 1-year follow-up. Oswestry Disability Index (ODI) and visual analogue scale (VAS) for back and leg at 3-month and 1-year follow-up. RESULTS A total of 93 patients (41 uniplanar, 52 biplanar) were included. Both cage types provided significant postoperative improvements in anterior disc height, posterior disc height, and segmental lordosis at 1 year. No significant differences in cage subsidence rates were found between uniplanar (21.9%) and biplanar devices (32.7%) at 6 weeks (odds ratio, 2.015; 95% confidence interval, 0.651-6.235; p = 0.249) with no additional instances of subsidence at 1 year. No significant differences in the magnitude of improvements based on ODI, VAS back, or VAS leg at 3-month or 1-year follow-up between groups and the proportion of patients achieving the minimal clinically important difference in ODI, VAS back, or VAS leg at 1 year were not statistically significantly different (p > 0.05). Finally, there were no significant differences in complication rates (p = 0.283), 90-day readmission rates (p = 1.00), revision surgical procedures (p = 0.423), or fusion rates at 1 year (p = 0.457) between groups. CONCLUSION Biplanar and uniplanar expandable cages offer a safe and effective means of improving anterior disc height, posterior disc height, segmental lordosis, and patient-reported outcome measures at 1 year postoperatively. No significant differences in radiographic outcomes, subsidence rates, mean subsidence distance, 1-year patient-reported outcomes, and postoperative complications were noted between groups.
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Affiliation(s)
- Jonathan A. Ledesma
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jesse C. Ottaway
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark J. Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Azra Dees
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Terence L. Thomas
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark F. Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kris E. Radcliff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - David G. Anderson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Ledesma JA, Lambrechts MJ, Dees A, Thomas T, Hiranaka CG, Kurd MF, Radcliff KE, Anderson DG. Static versus Expandable Interbody Fusion Devices: A Comparison of 1-Year Clinical and Radiographic Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Asian Spine J 2023; 17:61-74. [PMID: 35785911 PMCID: PMC9977975 DOI: 10.31616/asj.2021.0486] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/26/2022] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE To compare the radiographic and clinical outcomes of static versus expandable interbody cages in transforaminal lumbar interbody fusion using minimally invasive surgery (MIS-TLIF). OVERVIEW OF LITERATURE Expandable interbody cages may potentially improve radiographic and clinical outcomes following MIS-TLIF compared to static pages, but at a potentially higher cost and increased rates of subsidence. METHODS A retrospective chart review of 1- and 2-level MIS-TLIFs performed from 2014 to 2020 was reviewed. Radiographic measurements were obtained preoperatively, 6 weeks postoperatively, and at final follow-up. Patient-reported outcome measures (PROMs) including the Oswestry Disability Index, Visual Analog Scale (VAS) back, and VAS leg were evaluated. Multivariate linear regression analysis determined the effect of cage type on the change in PROMs, controlling for demographic characteristics. Alpha was set at 0.05. RESULTS A total of 221 patients underwent MIS-TLIF including 136 static and 85 expandable cages. Expandable cages had significantly greater anterior (static: 11.41 mm vs. expandable: 13.11 mm, p <0.001) and posterior disk heights (static: 7.22 mm vs. expandable: 8.11 mm, p <0.001) at 1-year follow-up. Expandable cages offered similar improvements in segmental lordosis at 6 weeks (static: 1.69° vs. expandable: 2.81°, p =0.243), but segmental lordosis was better maintained with expandable cages leading to significant differences at 1-year follow-up (static: 0.86° vs. expandable: 2.45°, p =0.001). No significant differences were noted in total complication (static: 12.5% vs. expandable: 16.5%, p =0.191) or cage subsidence rates (static: 19.7% vs. expandable: 22.4%, p =0.502) groups at 1-year follow-up. CONCLUSIONS Expandable devices provide greater improvements in radiographic measurements including anterior disk height, posterior disk height, and segmental lordosis, but this did not lead to significant improvements in PROMs, complication rates, subsidence rates, or subsidence distance.
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Affiliation(s)
| | - Mark J Lambrechts
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Azra Dees
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Terence Thomas
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Mark Faisal Kurd
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kris E Radcliff
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - David Greg Anderson
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Issa TZ, Lee Y, Lambrechts MJ, Tran KS, Trenchfield D, Baker S, Fras S, Yalla GR, Kurd MF, Woods BI, Rihn JA, Canseco JA, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion. Neurosurg Focus 2023; 54:E7. [PMID: 36587401 DOI: 10.3171/2022.10.focus22607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/19/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate patient and surgical factors that predict increased overall lumbar lordosis (LL) and segmental lordosis correction following a minimally invasive lateral lumbar interbody fusion (LLIF) procedure. METHODS A retrospective review was conducted of all patients who underwent one- or two-level LLIF. Preoperative, initial postoperative, and 6-month postoperative measurements of LL, segmental lordosis, anterior disc height, and posterior disc height were collected from standing lateral radiographs for each patient. Cage placement was measured utilizing the center point ratio (CPR) on immediate postoperative radiographs. Spearman correlations were used to assess associations between cage lordosis and radiographic parameters. Multivariate linear regression was performed to assess independent predictors of outcomes. RESULTS A total of 106 levels in 78 unique patients were included. Most procedures involved fusion of one level (n = 50, 64.1%), most commonly L3-4 (46.2%). Despite no differences in baseline segmental lordosis, patients with anteriorly or centrally placed cages experienced the greatest segmental lordosis correction immediately (mean anterior 4.81° and central 4.46° vs posterior 2.47°, p = 0.0315) and at 6 months postoperatively, and patients with anteriorly placed cages had greater overall lordosis correction postoperatively (mean 6.30°, p = 0.0338). At the 6-month follow-up, patients with anteriorly placed cages experienced the greatest increase in anterior disc height (mean anterior 6.24 mm vs posterior 3.69 mm, p = 0.0122). Cages placed more posteriorly increased the change in posterior disc height postoperatively (mean posterior 4.91 mm vs anterior 1.80 mm, p = 0.0001) and at 6 months (mean posterior 4.18 mm vs anterior 2.06 mm, p = 0.0255). There were no correlations between cage lordotic angle and outcomes. On multivariate regression, anterior cage placement predicted greater 6-month improvement in segmental lordosis, while posterior placement predicted greater 6-month improvement in posterior disc height. Percutaneous screw placement, cage lordotic angle, and cage height did not independently predict any radiographic outcomes. CONCLUSIONS LLIF procedures reliably improve LL and increase intervertebral disc space. Anterior cage placement improves the lordosis angle greater than posterior placement, which better corrects sagittal alignment, but there is still a significant improvement in lordosis even with a posteriorly placed cage. Posterior cage placement provides greater restoration in posterior disc space height, maximizing indirect decompression, but even the anteriorly placed cages provided indirect decompression. Cage parameters including cage height, lordosis angle, and material do not impact radiographic improvement.
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Affiliation(s)
- Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark J. Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Khoa S. Tran
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Delano Trenchfield
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sydney Baker
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sebastian Fras
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Goutham R. Yalla
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark F. Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Barrett I. Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeffrey A. Rihn
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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Lin GX, Kim JS, Kotheeranurak V, Chen CM, Hu BS, Rui G. Does the application of expandable cages in TLIF provide improved clinical and radiological results compared to static cages? A meta-analysis. Front Surg 2022; 9:949938. [PMID: 36034361 PMCID: PMC9400024 DOI: 10.3389/fsurg.2022.949938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose This study aimed to provide a direct meta-analysis of the evidence comparing outcomes between expandable cages and static cages in patients with transforaminal lumbar interbody fusion (TLIF). Methods A search of relevant materials from databases was performed from inception to March 7, 2022. Clinical and radiological outcomes were included. Results Ten studies (1,440 patients) were included. The anterior disc height and foraminal height for expandable cages were substantially higher than those for static cages at the final follow-up (P < 0.0001; P = 0.05). In comparison with static cages, although not statistically significant, expandable cages showed beneficial results, including an increase in posterior disc height and segmental lordosis. There were no statistically significant differences in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rates (P > 0.05). Oswestry disability index scores for expandable cages were substantially lower than those for static cages at the final follow-up (P = 0.0007). Interestingly, although the preoperative visual analog scores for back and leg pain were significantly higher in the expandable group than in the static group (P < 0.0001; P = 0.008), there was no significant difference between the static and expandable groups during the final follow-up (P = 0.51; P = 0.85). Conclusions Expandable cages are associated with improved functional outcomes and restored postoperative disc and foraminal heights in patients with TLIF. In addition, no statistically significant differences were observed in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rate.
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Affiliation(s)
- Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Vit Kotheeranurak
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Correspondence: Chien-Min Chen Gang Rui Bao-Shan Hu
| | - Bao-Shan Hu
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
- Correspondence: Chien-Min Chen Gang Rui Bao-Shan Hu
| | - Gang Rui
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
- Correspondence: Chien-Min Chen Gang Rui Bao-Shan Hu
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Toop N, Grossbach A, Gibbs D, Akhter A, Keister A, Maggio D, Oosten J, Deistler K, Gilkey T, Farhadi HF, Viljoen S. Static cage morphology in short-segment transforaminal lumbar interbody fusions is associated with alterations in foraminal height but not clinical outcomes. World Neurosurg 2021; 159:e389-e398. [PMID: 34954441 DOI: 10.1016/j.wneu.2021.12.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Steerable "banana" cages have been posited to increase segmental lordosis in short-segment transforaminal lumbar interbody fusions (TLIF). The same is not necessarily true for straight "bullet" cages. While increased lordosis is generally thought to be advantageous, a potential complication is decreased foraminal height. Here we evaluate for any association between cage type and change in foraminal height and clinical outcomes following short-segment TLIFs. METHODS We retrospectively reviewed consecutive one- and two-level TLIFs with bilateral facetectomies with minimum one-year clinical and radiographic follow-up. Two cohorts were based on cage morphology: steerable "banana" cage or straight "bullet" cage. Patient reported outcome measures (PROMs), radiographic measurements, and revision rates were compared. RESULTS 46 patients with 53 straight and 95 patients with 131 steerable cage levels were included. Steerable cages showed increased segmental lordosis (9.1 vs 13.5°, p<0.001) and decreased foraminal height (20.3 vs 18.5 mm, p<0.001) after surgery. Straight cages demonstrated similar segmental lordosis (8.7 vs 8.1°, p=0.30) and foraminal height (19.4 vs 20.0 mm, p=0.065). Both cohorts showed improved PROMs at last follow-up (p≤0.005). Sub-analysis comparing patients that had increased or decreased foraminal height revealed similarly improved PROMs between cohorts. Revision rates at one-year were similar between cohorts (4.3% for straight and 3.2% for steerable group, p=0.72). CONCLUSION Although the increased segmental lordosis afforded by placement of steerable cages may decrease foraminal height after short segment TLIF, clinical outcomes are not negatively affected by this association.
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Affiliation(s)
- Nathaniel Toop
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Andrew Grossbach
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - David Gibbs
- The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Asad Akhter
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Keister
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dominic Maggio
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James Oosten
- The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Kyle Deistler
- The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Ty Gilkey
- The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - H Francis Farhadi
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States.
| | - Stephanus Viljoen
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Woodward J, Koro L, Richards D, Keegan C, Fessler RD, Fessler RG. Expandable vs. Static Transforaminal Lumbar Interbody Fusion Cages: 1-year Radiographic Parameters and Patient Reported Outcomes. World Neurosurg 2021; 159:e1-e7. [PMID: 34801752 DOI: 10.1016/j.wneu.2021.11.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Expandable transforaminal lumbar interbody fusion (TLIF) cages capable of multidirectional in situ expansion have gained popularity as they increase axial surface area for fusion and may enhance lordotic correction through a traditional MIS surgical corridor. OBJECTIVE To evaluate and compare the radiographic and clinical outcomes between a novel expandable vs. static MIS TLIF cage for the treatment of degenerative disc disease. STUDY DESIGN A single center retrospective review of 120 consecutive adult patients undergoing 1 or 2-level MIS TLIF with an expandable (n=60) or static cage was performed between 2015-2019. Preoperative and 1-year postoperative radiographic and clinical outcomes were assessed by upright flexion/extension radiographs and serial confidential surveys. RESULTS 120 patients (mean age 63.5 years, 60.0 % female) undergoing 1 and 2-level MIS TLIF met inclusion criteria. A statistically significant reduction of spondylolisthesis, restoration of foraminal, anterior and posterior disc height was achieved in both cohorts, but greater in the ECC (all p<0.05). Comparable rates of fusion, 93% and 91% were observed in the ECC and SCC. A significant reduction in NRS back and ODI scores were observed in both cohorts but more pronounced in the ECC (5.9±2.4 to 2.2±1.9 and 37.3±16.2 to 17.1±15.2) vs. SCC (6.2±2.8 to 3.2±2.5 and 41.8±16.1 to 24.3±17.5) (p<0.05). One instance of cage migration requiring reoperation occurred in the ECC. CONCLUSIONS Taken together, these radiographic and clinical findings suggest an expandable cage placed through an MIS corridor represents a safe, equitable and efficacious alternative to a static TLIF in adults with degenerative lumbar pathology.
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Affiliation(s)
- Josha Woodward
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Lacin Koro
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Dominick Richards
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Christopher Keegan
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard D Fessler
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA.
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Armocida D, Pesce A, Cimatti M, Proietti L, Santoro A, Frati A. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Cages: Increased Risk of Late Postoperative Subsidence Without a Real Improvement of Perioperative Outcomes: A Clinical Monocentric Study. World Neurosurg 2021; 156:e57-e63. [PMID: 34492389 DOI: 10.1016/j.wneu.2021.08.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is one of several approaches to lumbar interbody fusion that has proven to be a safe and effective treatment for symptomatic lumbar degenerative disease The clinical outcomes of MIS-TLIF are generally favorable, but there is still controversy regarding its ability to restore sagittal alignment. For this reason, expandable transforaminal lumbar interbody fusion cages have been developed and designed to improve ability to restore disc height and segmental lordosis. The use of expandable cages in transforaminal lumbar interbody fusion has increased drastically; however, it is not clear how effective cage expansion is in regard to disc space lordosis, distraction, and long-term outcome. METHODS We reviewed a cohort of patients with symptomatic lumbar degenerative disc pathology who underwent MIS-TLIF at our institution. We compared clinical and radiographic outcomes of expandable versus nonexpandable cage use in MIS-TLIF focusing on mean changes in segmental lordosis, disc height, and postoperative complications. The results were compared with other studies reported in the international literature. RESULTS Mean change in segmental lordosis was not significantly different between the 2 groups. A significantly higher rate of postoperative subsidence was demonstrated in the expandable cage group. CONCLUSION This study established that expandable cage use in single-level transforaminal lumbar interbody fusion did not reduce the rate of postoperative complications, but rather significantly increased a patient's risk of postoperative subsidence. Expandable cages do not presently demonstrate improved clinical outcomes or improved sagittal alignment compared with static cages.
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Affiliation(s)
- Daniele Armocida
- Human Neurosciences Department, Sapienza University, Rome, Italy.
| | | | - Marco Cimatti
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy; Institute of Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Santoro
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Alessandro Frati
- Human Neurosciences Department, Sapienza University, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy
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Glennie RA, Bailey CS, Abraham E, Manson N, Casha S, Thomas K, Paquet J, McIntosh G, Hall H, Fisher CG, Rampersaud YR. Variation in surgical treatment of degenerative spondylolisthesis in Canada: surgeon assessment of stability and impact on treatment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3709-3719. [PMID: 34327542 DOI: 10.1007/s00586-021-06928-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Controversy exists regarding the optimal surgical treatment of degenerative lumbar spondylolisthesis (DS). Not all DS patients are the same, and the degree to which inherent stability may dictate treatment is unknown. The purpose of this study was to determine the variability in surgical approach relative to surgeon classified stability. The secondary objective was to compare patient-reported outcomes (PROs) across different surgical techniques and grades of stability. METHODS Patients prospectively enrolled from eleven tertiary care institutions and followed from 2015 to 2019. The surgical technique was at the surgeon's discretion. Surgeons were asked to grade the degree of instability based on the degenerative spondylolisthesis instability classification system (DSIC). DSIC categorizes three different types (I-stable, II-potentially unstable, and III-unstable). One-year changes in PROs were compared between each group. Multivariable regression was used to identify any characteristics that explained variability in treatment. RESULTS There were 323 patients enrolled in this study. Surgeons' stability classification versus procedure [decompression alone (D)/decompression and posterolateral fusion (D-PL)/and decompression with posterior/transforaminal lumbar interbody fusion (D-PLIF/TLIF)] were as follows: type I (n = 91): D-41%/D-PL-13%/D-PLIF/TLIF-46%; type II (n = 175): D-23%/D-PL-17%/D-PLIF/TLIF-60%; and type III (n = 57):(D-0%/D-PL-14%/D-PLIF/TLIF-86%). Type I patients undergoing D-PL had some improvements in EQ-5D and NRS versus those undergoing D-PLIF/TLIF but otherwise there were no other significant differences between groups. Regression analysis demonstrated advanced age (OR = 1.06, CI 1.02-10.12) and type I (OR = 2.61, CI 1.17-5.81) were associated with receiving decompression surgery alone. CONCLUSIONS There exists considerable variation in surgical management of DS in Canada. Given similar PROs in two of the three groups, there is potential to tailor surgical intervention and improve resource utilization.
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Affiliation(s)
- R Andrew Glennie
- Department of Surgery, Dalhousie University, Halifax, NS, Canada.
| | | | | | - Neil Manson
- Canada East Spine Center, Saint John, NB, Canada
| | - Steve Casha
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Kenneth Thomas
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Jerome Paquet
- CHU Laval: Centre Hospitalier de l'Universite Laval, Quebec, Canada
| | - Greg McIntosh
- The University of British Columbia, Vancouver, BC, Canada
| | - Hamiton Hall
- University of Toronto Faculty of Medicine, Toronto, ON, Canada
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14
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Canseco JA, Karamian BA, DiMaria SL, Patel PD, Divi SN, Chang M, Timmons T, Grewal L, Hallman H, Lee JK, Kaye ID, Woods BI, Kurd MF, Anderson DG, Rihn JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Static Versus Expandable Polyether Ether Ketone (PEEK) Interbody Cages: A Comparison of One-Year Clinical and Radiographic Outcomes for One-Level Transforaminal Lumbar Interbody Fusion. World Neurosurg 2021; 152:e492-e501. [PMID: 34098137 DOI: 10.1016/j.wneu.2021.05.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine the effect of static versus expandable polyether ether ketone (PEEK) cages on both clinical and radiographic outcomes. METHODS A retrospective cohort study was conducted on patients who underwent one-level transforaminal lumbar interbody fusion with either a static or expandable PEEK cage. Patient outcomes were obtained from chart review and radiographic outcomes were measured using standing, lateral radiographs. Recovery ratios and the proportion of patients achieving the minimally clinically important difference were calculated for Oswestry Disability Index (ODI), Physical Component Score-12, Mental Component Score-12, visual analogue scale for back, and visual analogue scale for leg at 1 year and compared between groups. Multivariate linear regression analysis was performed to determine the effect of cage type on the change in patient-reported outcome measures, controlling for demographic factors. RESULTS A total of 240 patients (137 static, 103 expandable) were included in the final analysis. ΔPhysical Component Score-12 scores at 3 months were significantly greater for the static group (16.0 vs. 10.0, P = 0.043) compared with the expandable group. Multivariate regression demonstrated that use of an expandable cage was associated with greater improvements in ΔODI (β: -7.82, P = 0.048) at 1 year. No differences were found in the perioperative change in sagittal spinal alignment within or between groups at 1 year. Subsidence rates failed to show any statistically significant difference between the 2 groups. CONCLUSIONS Transforaminal lumbar interbody fusion with an expandable PEEK cage is an independent predictor of improved ODI scores at 1 year. Our study showed no significant differences in subsidence rates or changes in sagittal spinal alignment between static and expandable PEEK cages.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Stephen L DiMaria
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parthik D Patel
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Srikanth N Divi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Chang
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tyler Timmons
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lovy Grewal
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haydn Hallman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph K Lee
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - D Greg Anderson
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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15
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Lumbar interbody fusion: recent advances in surgical techniques and bone healing strategies. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:22-33. [DOI: 10.1007/s00586-020-06596-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
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