1
|
Srirangarajan T, Eseonu K, Fakouri B, Liantis P, Panteliadis P, Lucas J, Ember T, Harris M, Tyrrell M, Sandford B, Panchmatia JR. Retrospective analysis of medium-term outcomes following anterior lumbar interbody fusion surgery performed in a tertiary spinal surgical centre. Ann R Coll Surg Engl 2024; 106:540-546. [PMID: 38478070 PMCID: PMC11217818 DOI: 10.1308/rcsann.2023.0082] [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] [Accepted: 10/05/2023] [Indexed: 07/02/2024] Open
Abstract
INTRODUCTION Anterior lumbar interbody fusion (ALIF) can treat spondylolisthesis, degenerative disc disease and pseudoarthrosis. This approach facilitates complete discectomy, disc space distraction, indirect decompression of neural foramina and placement of large interbody devices. Several intra- and postoperative complications can be attributed to the anterior approach: vascular/visceral injury, hypogastric plexus injury and urogenital consequences. Spine-specific complications include implant migration, graft failure, pseudoarthrosis and persistent symptomology. METHODS This retrospective study reviewed patient demographics, medium-term outcomes and complication rates following ALIF surgery performed over a 5-year period. A total of 110 consecutive patients had undergone ALIF surgery at a single tertiary spinal centre. The database was reviewed with a primary outcome of identifying postoperative 90-day complications and whether a revision anterior operation was required after primary ALIF. RESULTS No patients required revision anterior operation after their primary ALIF surgery by final follow-up. Out of 110 patients, 11 (10%) recorded a complication attributed to the anterior stage of their operation within 90 days. CONCLUSIONS Our 90-day complication rate of 10% lies within the 2.6% acute complication and 40% overall complications rates described in previous literature. The risk of vascular/visceral injury is significant (3%) and we recommend that ALIF be performed as a dual surgeon procedure with a vascular-trained access surgeon accompanying the spinal surgeon. ALIF is a valid revision surgical option for failed posterior approaches leading to complications such as pseudoarthrosis. In our sample, 89% of patients were managed with posterior fixation to augment the anterior fusion as, biomechanically, this is a proven construct.
Collapse
Affiliation(s)
| | - K Eseonu
- Guy’s and St Thomas’ NHS Foundation Trust
| | - B Fakouri
- Guy’s and St Thomas’ NHS Foundation Trust
| | - P Liantis
- Guy’s and St Thomas’ NHS Foundation Trust
| | | | - J Lucas
- Guy’s and St Thomas’ NHS Foundation Trust
| | - T Ember
- Guy’s and St Thomas’ NHS Foundation Trust
| | - M Harris
- Guy’s and St Thomas’ NHS Foundation Trust
| | - M Tyrrell
- Guy’s and St Thomas’ NHS Foundation Trust
| | - B Sandford
- Guy’s and St Thomas’ NHS Foundation Trust
| | | |
Collapse
|
2
|
Alhaug OK, Dolatowski FC, Thyrhaug AM, Mjønes S, Dos Reis JABPR, Austevoll I. Long-term comparison of anterior (ALIF) versus transforaminal (TLIF) lumbar interbody fusion: a propensity score-matched register-based study. 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 2024; 33:1109-1119. [PMID: 38078979 DOI: 10.1007/s00586-023-08060-1] [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: 08/24/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 03/19/2024]
Abstract
PURPOSE Anterior (ALIF) and transforaminal (TLIF) lumbar interbody fusion have shown similar clinical outcomes at short- and medium-term follow-ups. Possible advantages of ALIF in the long run could be better disc height and lumbar lordosis and reduced risk of adjacent segment disease. We aimed to study if ALIF could be associated with superior clinical outcomes than TLIF at long-term follow-up. METHODS We analysed 535 patients treated with ALIF or TLIF of the L5-S1 spinal segment between 2007 and 2017 who completed long-term follow-up in a national spine registry database (NORspine). We defined treatment success after surgery as at least 30% improvement in Oswestry Disability Index (ODI) at long-term follow-up. Patients treated with ALIF and TLIF and who responded at long term were balanced by propensity score matching. The proportions of successfully treated patients within each group were compared by numbers and percentages with corresponding relative risk. RESULTS The mean (95%CI) age of the total study population was 50 (49-51) years, and 264 (49%) were females. The mean (95%CI) preoperative ODI score was 40 (39-42), and 174 (33%) had previous spine surgery. Propensity score matching left 120 patients in each treatment group. At a median (95%CI) of 92 (88-97) months after surgery, we found no difference in proportions successfully treated patients with ALIF versus TLIF (68 (58%) versus 77 (65%), RR (95%CI) = 0.88 (0.72 to1.08); p = 0.237). CONCLUSIONS This propensity score-matched national spine register study of patients treated with ALIF versus TLIF of the lumbosacral junction found no differences in proportions of successfully treated patients at long-term follow-up. LEVEL OF EVIDENCE I Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.
Collapse
Affiliation(s)
- Ole Kristian Alhaug
- The Research Center for Age-Related Functional Decline and Disease, Innlandet Hospital Trust, PO Box 68, 2313, Ottestad, Norway.
- Norwegian University of Science and Technology, NTNU, PO Box 191, 7491, Trondheim, Norway.
- Orthopaedic Department, Akershus University Hospital, PO Box 1000, 1478, Loerenskog, Norway.
| | - Filip C Dolatowski
- Orthopaedic Department, Oslo University Hospital, PO Box 4956, 0424, Oslo, Norway
| | | | - Sverre Mjønes
- Orthopaedic Department, Akershus University Hospital, PO Box 1000, 1478, Loerenskog, Norway
| | | | - Ivar Austevoll
- Orthopaedic Department, Kysthospitalet in Hagavik, Haukeland University Hospital, 5217, Hagevik, Bergen, Norway
| |
Collapse
|
3
|
Walia A, Ani F, Maglaras C, Raman T, Fischer C. Resolution of Radiculopathy Following Indirect Versus Direct Decompression in Single Level Lumbar Fusion. Global Spine J 2024:21925682241230926. [PMID: 38315111 DOI: 10.1177/21925682241230926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES To evaluate resolution of radiculopathy in one-level lumbar fusion with indirect or direct decompression techniques. METHODS Patients ≥18 years of age with preoperative radiculopathy undergoing single-level lumbar fusion with up to 2-year follow-up were grouped by indirect and direct decompression. Direct decompression (DD) group included ALIF and LLIF with posterior DD procedure as well as all TLIF. Indirect decompression (ID) group included ALIF and LLIF without posterior DD procedure. Propensity score matching was used to control for intergroup differences in age. Intergroup outcomes were compared using means comparison tests. Logistic regressions were used to correlate decompression type with symptom resolution over time. Significance set at P < .05. RESULTS 116 patients were included: 58 direct decompression (DD) (mean 53.9y, 67.2% female) and 58 indirect decompression (ID) (mean 54.6y, 61.4% female). DD patients experienced greater blood loss than ID. Additionally, DD patients were 4.7 times more likely than ID patients to experience full resolution of radiculopathy at 3 months post-op. By 6 months, DD patients demonstrated larger reductions in VAS score. With regard to motor function, DD patients had improved motor score associated with the L5 dermatome at 6 months relative to ID patients. CONCLUSIONS Direct decompression was associated with greater resolution of radiculopathy in the near post-operative term, with no differences at long term follow-up when compared with indirect decompression. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms.
Collapse
Affiliation(s)
- Arnaav Walia
- NYU Langone Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Fares Ani
- NYU Langone Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Constance Maglaras
- NYU Langone Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Tina Raman
- NYU Langone Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Charla Fischer
- NYU Langone Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| |
Collapse
|
4
|
Lee D, Lee R, Fassihi SC, Ramamurti P, Heyer JH, Iweala U, Weinreb J, O’Brien J. Risk Factors for Blood Transfusions in Elective Single-Level Anterior Lumbar Interbody Fusion for Degenerative Conditions. THE IOWA ORTHOPAEDIC JOURNAL 2023; 43:106-116. [PMID: 38213855 PMCID: PMC10777706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Background ALIF (anterior lumbar interbody fusion) and other spinal fusion surgeries are among the most common orthopaedic procedures requiring blood transfusions. However, blood transfusions have been associated with various complications, including adverse reactions and infections. The present study aims to identify independent risk factors for blood transfusions in patients undergoing single-level ALIF specifically to better identify high risk patients and optimize perioperative management. Methods All patients who had undergone single-level ALIF patients for the treatment of degenerative spinal conditions, excluding traumatic, pathologic, and infectious etiologies, were identified by querying a multi-institutional surgical registry from 2005 to 2018. Multi-level fusions, PLIF/TLIF, and posterior procedures were also excluded. Mann-Whitney-U-Tests were used to analyze continuous variables, while Fisher's-Exact-Tests/Bonferroni-Corrected-Tests were used for categorical variables. Multivariate logistic regression analysis with alternating backward stepwise elimination and forward entry was implemented to identify significant predictors for blood transfusions within 72 hours after incision. The predicted probabilities were used in post-regression diagnostics to generate a Receiver Operating Characteristic (ROC) curve to assess model performance. Results 4,792 single-level ALIF patients met inclusion criteria - 183 (3.82%) had received blood transfusions within 72 hours after incision and 4,609 (96.18%) had not. Age ≥60 years (OR 1.954, p<0.001), preoperative transfusions (OR 33.758, p=0.023), extended operative times (≥197.0 minutes; 75th percentile) (OR 4.645, p<0.001), ASA≥3 (OR 1.395, p<0.001) and preoperative hematocrit levels (Hct) 30.00-37.99 (OR 1.562, p=0.016) and Hct <30.00 (OR 6.334, p<0.001) were shown to be significant independent risk factors for perioperative blood transfusions. The area under the ROC curve (AUROC; C-statistic) was 0.759 (p<0.001), indicating relatively strong discriminatory ability/predictability of the final model. Conclusion Several independent risk factors including age ≥60 years, preoperative blood transfusions and extended operative times increased risk for blood transfusion following single-level ALIF. The present study aims to help surgeons identify high-risk patients to better communicate postoperative expectations and optimize patients to reduce the risk of transfusions and secondary complications. Level of Evidence: III.
Collapse
Affiliation(s)
- Danny Lee
- Department of Orthopaedic Surgery, University of Miami-Jackson Memorial Health System, Miami, Florida, USA
| | - Ryan Lee
- Department of Surgery, Department of Anesthesiology and Perioperative Care, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Safa C. Fassihi
- Department of Orthopaedic Surgery, New York University, New York, New York, USA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jessica H. Heyer
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Uchechi Iweala
- Division of Spine Surgery, Centers for Advanced Orthopaedics, Bethesda, Maryland, USA
| | - Jeffrey Weinreb
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| | - Joseph O’Brien
- Washington Spine and Scoliosis Institute, OrthoBethesda, Bethesda, Maryland, USA
- Department of Spine Surgery, Virginia Hospital Center, Arlington, Virginia, USA
| |
Collapse
|
5
|
Tao X, Matur AV, Khalid S, Onyewadume L, Garner R, McGrath K, Owen B, Gibson J, Cass D, Mejia Munne JC, Vorster P, Shukla G, Gupta S, Wu A, Childress K, Palmisciano P, Duah HO, Motley B, Cheng J, Adogwa O. TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis. Spine (Phila Pa 1976) 2023; 48:1335-1341. [PMID: 37146059 DOI: 10.1097/brs.0000000000004694] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/10/2023] [Indexed: 05/07/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for the treatment of degenerative stenosis and spondylolisthesis. SUMMARY OF BACKGROUND DATA ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. METHODS A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010 and 2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery, and secondary outcomes were all-cause medical and surgical complications. RESULTS Exact 1:1 matching resulted in 2 equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001) and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P =0.002). All-cause surgical complications were not significantly different between both groups. CONCLUSION After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. LEVEL OF EVIDENCE Level-3.
Collapse
Affiliation(s)
- Xu Tao
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Abhijith V Matur
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed Khalid
- Department of Neurosurgery, University of Illinois College of Medicine, Chicago, IL
| | - Louisa Onyewadume
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, MA
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Rebecca Garner
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyle McGrath
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Bryce Owen
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Justin Gibson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daryn Cass
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Juan C Mejia Munne
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Phillip Vorster
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Geet Shukla
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sahil Gupta
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew Wu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kelly Childress
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Henry O Duah
- Institute for Nursing Research & Scholarship, University of Cincinnati College of Nursing, Cincinnati, OH
| | - Benjamin Motley
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
6
|
Graves JC, Zaki PG, Hancock J, Locke KC, Luck T. The Anterior Versus Posterior Approach for Interbody Fusion in Patients Who Are Classified as Obese: A Retrospective Cohort Study of 9,021 Patients From a National Database. Cureus 2023; 15:e44861. [PMID: 37809266 PMCID: PMC10560096 DOI: 10.7759/cureus.44861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Lumbar spine interbody fusions have been performed to relieve back pain and improve stability due to various underlying pathologies. Anterior interbody fusion and posterior interbody fusion approaches are two main approaches that are classically compared. In an attempt to compare these two approaches to the spine, large retrospective national database reviews have been performed to compare and predict 30-day postoperative outcomes; however, they have conflicting findings. Obesity, defined as having a body mass index (BMI) over 30 kg/m2, may also contribute to the extent of spine pathology and is associated with increased rates of postoperative complications. Complication rates in patients who are obese have yet to be thoroughly investigated using a large national database. Our present investigation aims to make this comparison using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The goal of the present study is to utilize a nationwide prospective database to determine short-term differences in postoperative outcomes between posterior and anterior lumbar fusion in patients with obesity and relate these findings to previous studies in the general population. Methods A retrospective cohort analysis was conducted on 9,021 patient data from the ACS-NSQIP database from 2015 to 2019 who underwent an elective, single-level fusion via anterior or posterior surgical approach. This database captures over 150 clinical variables on individual patient cases, including demographic data, preoperative risk factors and laboratory values, intraoperative data, and significant events up to postoperative day 30. All outcome measures were included in this analysis with special attention to rates of deep venous thrombosis (DVT) and pulmonary embolism (PE), prolonged length of stay (LOS), reoperation, and operation time. Results Multivariable analysis controlling for age, BMI, sex, race, functional status, American Society of Anesthesiologists (ASA) class, and selected comorbidities with P < 0.05 demonstrated that the anterior approach was an independent predictor for all significant outcomes except prolonged length of stay. Compared to the posterior approach, the anterior approach had a shorter total operation time (B = -13.257, 95% confidence interval (CI) [-17.522, -8.992], P < 0.001), higher odds of deep vein thrombosis (odds ratio (OR) = 2.210, 95% CI [1.211, 4.033], P= 0.010), and higher odds of pulmonary embolism (OR = 2.679, 95% CI [1.311, 5.477], P = 0.007) and was protective against unplanned reoperation (OR = 0.702, 95% CI [0.548, 0.898], P = 0.005). Conclusions The obese population makes up a large and growing demographic of those undergoing spine surgery, and as such, it is pertinent to investigate the differences, advantages, and disadvantages of lumbar fusion approaches in this group. While anterior approaches may be protective of longer operation time and unplanned reoperation, this benefit may not be clinically significant when considering an increased risk of DVT and PE. Given the short-term nature of this dataset and the limitations inherent in large de-identified retrospective database studies, these findings are interpreted with caution. Longer-term follow-up studies accounting for confounding variables with spine-centered outcomes will be necessary to further elucidate these nuances.
Collapse
Affiliation(s)
- Josette C Graves
- Neurosurgery, Drexel University College of Medicine, Wyomissing, USA
| | - Peter G Zaki
- Neurosurgery, Drexel University College of Medicine, Wyomissing, USA
| | - Joshua Hancock
- Neurosurgery, Drexel University College of Medicine, Wyomissing, USA
| | - Katherine C Locke
- Medicine, Drexel University College of Medicine, Wyomissing, USA
- Neurological Surgery, University at Buffalo, Buffalo, USA
| | - Trevor Luck
- Orthopedic Surgery, St. Luke's University Health Network, Philadelphia, USA
| |
Collapse
|
7
|
Kim YH, Ha KY, Kim YS, Kim KW, Rhyu KW, Park JB, Shin JH, Kim YY, Lee JS, Park HY, Ko J, Kim SI. Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J 2022; 16:1022-1033. [PMID: 36573302 PMCID: PMC9827209 DOI: 10.31616/asj.2022.0435] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.
Collapse
Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Youn-Soo Kim
- Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ki-Won Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Hyuk Shin
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Yul Kim
- Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeryong Ko
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Corresponding author: Sang-Il Kim Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6775, Fax: +82-2-535-9837, E-mail:
| |
Collapse
|
8
|
Hartman TJ, Nie JW, MacGregor KR, Oyetayo OO, Zheng E, Singh K. Impact of gender on outcomes following single-level anterior lumbar interbody fusion. J Clin Orthop Trauma 2022; 34:102019. [PMID: 36161065 PMCID: PMC9490097 DOI: 10.1016/j.jcot.2022.102019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 10/31/2022] Open
Abstract
Background There have been a multitude of studies attempting to identify the relationship between gender and postoperative outcomes; however, few studies have examined how this relationship may affect outcomes after anterior lumbar interbody fusion (ALIF) surgery. We aim to better characterize the impact that self-reported gender may have on patient reported outcome measures (PROMs) and achievement rates of minimum clinically important difference (MCID) after ALIF. Methods A retrospective database of a single spine surgeon was searched for patients who had undergone single-level ALIF. Indications for surgery including acute trauma, infection, or malignancy were excluded. The population was separated into cohorts by self-reported gender, female or male. PROMs were recorded and compared within groups to their preoperative baselines and between groups. MCID achievement rate was compared between groups. Results 140 patients were identified for this study, with 68 patients self-identifying as female gender. The male gender cohort was found to have a significantly greater prevalence of hypertension (p = 0.018). Both cohorts showed significant improvement during at least one or more postoperative time points for each evaluated outcome measure (p ≤ 0.048, all). No significant difference in mean PROM scores was noted between cohorts at any time point for any measured outcome. The female gender cohort had significantly greater MCID achievement rates for visual acuity scale (VAS) back pain overall and at the 6-month time point (p ≤ 0.043, both). The female gender cohort also had significantly greater achievement of MCID at the 1-year time point for VAS leg pain (p = 0.017). Conclusion Both female and male gender cohorts demonstrated significant improvement in all outcomes measured at one or more postoperative time points. Postoperative outcomes did not differ by gender. MCID achievement was more common in female patients. Female patients may experience more tangible clinical improvement after ALIF compared to male patients.
Collapse
Affiliation(s)
- Timothy J. Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - James W. Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Keith R. MacGregor
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Omolabake O. Oyetayo
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Eileen Zheng
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| |
Collapse
|
9
|
Karamian BA, Lambrechts MJ, Mao J, D'Antonio ND, Conaway W, Canseco JA, Thandoni A, Singh A, Harlamova D, Kaye ID, Kurd M, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Adult Isthmic Spondylolisthesis: A Radiographic and Outcomes Analysis Comparing Circumferential Fusions Versus TLIF Procedures. Clin Spine Surg 2022; 35:E660-E666. [PMID: 35385406 DOI: 10.1097/bsd.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS). SUMMARY OF BACKGROUND DATA Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique. METHODS Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set at P -value <0.05. RESULTS A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) ( P =0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99, P <0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm, P <0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm, P <0.001). Both groups significantly improved in all PROMs ( P <0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%, P =0.049), there was no difference in the rate of 30-day readmissions ( P =0.520) or revision surgeries between techniques ( P =0.057). CONCLUSIONS Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.
Collapse
Affiliation(s)
- Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Jennifer Mao
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - William Conaway
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | | | - Akash Singh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Daria Harlamova
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital
| |
Collapse
|
10
|
Singh K, Cha EDK, Lynch CP, Nolte MT, Parrish JM, Jenkins NW, Jacob KC, Patel MR, Vanjani NN, Pawlowski H, Prabhu MC, Myers JA. Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions. Clin Spine Surg 2022; 35:E601-E609. [PMID: 35344514 DOI: 10.1097/bsd.0000000000001322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity. METHODS Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient. RESULTS A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades. CONCLUSION Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.
Collapse
|
11
|
Ashayeri K, Alex Thomas J, Braly B, O'Malley N, Leon C, Cheng I, Kwon B, Medley M, Eisen L, Protopsaltis TS, Buckland AJ. Lateral decubitus single position anterior-posterior (AP) fusion shows equivalent results to minimally invasive transforaminal lumbar interbody fusion at one-year follow-up. 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 2022; 31:2227-2238. [PMID: 35551483 DOI: 10.1007/s00586-022-07226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study compares perioperative and 1-year outcomes of lateral decubitus single position circumferential fusion (L-SPS) versus minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for degenerative pathologies. METHODS Multicenter retrospective chart review of patients undergoing AP fusion with L-SPS or MIS TLIF. Demographics and clinical and radiographic outcomes were compared using independent samples t tests and chi-squared analyses with significance set at p < 0.05. RESULTS A total of 445 patients were included: 353 L-SPS, 92 MIS TLIF. The L-SPS cohort was significantly older with fewer diabetics and more levels fused. The L-SPS cohort had significantly shorter operative time, blood loss, radiation dosage, and length of stay compared to MIS TLIF. 1-year follow-up showed that the L-SPS cohort had higher rates of fusion (97.87% vs. 81.11%; p = 0.006) and lower rates of subsidence (6.38% vs. 38.46%; p < 0.001) compared with MIS TLIF. There were significantly fewer returns to the OR within 1 year for early mechanical failures with L-SPS (0.0% vs. 5.4%; p < 0.001). 1-year radiographic outcomes revealed that the L-SPS cohort had a greater LL (56.6 ± 12.5 vs. 51.1 ± 15.9; p = 0.004), smaller PI-LL mismatch (0.2 ± 13.0 vs. 5.5 ± 10.5; p = 0.004). There were no significant differences in amount of change in VAS scores between cohorts. Similar results were seen after propensity-matched analysis and sub-analysis of cases including L5-S1. CONCLUSIONS L-SPS improves perioperative outcomes and does not compromise clinical or radiographic results at 1-year follow-up compared with MIS TLIF. There may be decreased rates of early mechanical failure with L-SPS.
Collapse
Affiliation(s)
- Kimberly Ashayeri
- Department of Neurosurgery, NYU Langone Medical Center, 462 1st Avenue, Suite 7S4, New York, NY, USA.
| | - J Alex Thomas
- Atlantic Neurosurgical and Spine Specialists, Wilmington, NC, USA
| | - Brett Braly
- Oklahoma Sports, Science and Orthopaedics, Oklahoma City, OK, USA
| | | | - Carlos Leon
- Oklahoma Sports, Science and Orthopaedics, Oklahoma City, OK, USA
| | | | - Brian Kwon
- Division of Spine Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Mark Medley
- Department of Neurosurgery, NYU Langone Medical Center, 462 1st Avenue, Suite 7S4, New York, NY, USA
| | - Leon Eisen
- Oklahoma Sports, Science and Orthopaedics, Oklahoma City, OK, USA
| | | | | |
Collapse
|
12
|
Mortazavi A, Mualem W, Dowlati E, Alexander H, Rotter J, Withington C, Margolis M, Voyadzis JM. Anterior lumbar interbody fusion: single institutional review of complications and associated variables. Spine J 2022; 22:454-462. [PMID: 34600108 DOI: 10.1016/j.spinee.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/10/2021] [Accepted: 09/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT As more patients undergo anterior lumbar interbody fusion (ALIF) procedures and more devices are created for that purpose, it is important to understand the complications that can arise and the variables that mitigate risk for major and minor complications. PURPOSE To assess complication rates after ALIF with or without posterior instrumentation and variables associated with increased likelihood of postoperative complications. We aim to provide this data as benchmarking to improve patient safety and surgical care. STUDY DESIGN A single-center retrospective cohort study. PATIENT SAMPLE All adult patients who underwent ALIF between 2017 and 2019 was performed OUTCOME MEASURES: Post-operative major and minor complications were evaluated. METHODS Complications were recorded and presented as percentages. Patient demographics, perioperative, and postoperative data were also collected and analyzed between patients who had no complications and those that had any complication. Subgroup analysis of surgical complications were performed by nonparametric Chi-square tests. Continuous variables were compared using Mann-Whitney U tests. RESULTS Ninty-five of three hundred sixty-two (26.2%) of patients experienced a minor or major complication. Among the most common complications found were surgical site infections (5.8%), neurological complications (4.1%), vascular complications (3.6%), and urinary tract infections (3.3%). Patients undergoing ALIF alone with post-operative complications had higher mean age, higher BMI, higher ASA status, and experienced higher estimated blood loss. Patients undergoing ALIF and posterior instrumentation with post-operative complications were more likely to have diabetes and had a higher ASA status. Patients with any complications from both groups had longer length of stay, discharge to a non-home setting and were more likely to be readmitted or return to the operating room. CONCLUSION Our study reveals variables associated with complications at our institution, including age of the patient, BMI, and ASA status leading to higher complications and greater LOS, higher readmission rates, and disposition to skilled facilities.
Collapse
Affiliation(s)
- Armin Mortazavi
- Georgetown University School of Medicine, 3900 Reservoir Rd, Washington, DC, USA
| | - William Mualem
- Georgetown University School of Medicine, 3900 Reservoir Rd, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, 3800 Reservoir Rd, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Hepzibha Alexander
- Division of Neurosurgery, 16001 W Nine Mile Rd, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield, MI, USA
| | - Juliana Rotter
- Department of Neurological Surgery, 200 1st St NW, Mayo Clinic, Rochester, MN, USA
| | - Charles Withington
- Georgetown University School of Medicine, 3900 Reservoir Rd, Washington, DC, USA
| | - Marc Margolis
- Division of Thoracic Surgery, 3800 Reservoir Rd, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, 3800 Reservoir Rd, MedStar Georgetown University Hospital, Washington, DC, USA.
| |
Collapse
|
13
|
Kamalapathy PN, Bell J, Chen D, Raso J, Hassanzadeh H. Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion: No Increased Complications. Clin Spine Surg 2022; 35:E320-E326. [PMID: 34740230 DOI: 10.1097/bsd.0000000000001271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim were to (1) evaluate differences in postoperative outcomes and cost associated with outpatient anterior lumbar interbody fusion (ALIF) compared with inpatient ALIF, and to (2) identify independent factors contributing to complications after outpatient ALIF. SUMMARY OF BACKGROUND While lumbar fusion is traditionally performed inpatient, outpatient spinal surgery is becoming more commonplace as surgical techniques improve. METHODS The study population included all patients below 85 years of age who underwent elective ALIF (CPT-22558). Patients were then divided into those who underwent single-level fusion and multilevel fusion using the corresponding additional level fusion codes (CPT-22585). These resulting populations were then split into outpatient and inpatient cohorts by using a service location modifier. To account for selection bias, propensity score matching was performed; the inpatient cohorts were matched with respect to the outpatient cohorts based on age, sex, and Charlson Comorbidity Index. Statistical significance was set at P<0.05 and the Bonferroni correction was used for each multiple comparison (P<0.004). RESULTS Patients undergoing outpatient procedure had decreased rates of medical complications following both single-level and multilevel ALIF. In addition, age above 60, female sex, Charlson Comorbidity Index>3, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, hypertension, and tobacco use were all identified as independent risk factors for increased complications. Finally, the cost of outpatient ALIF was $12,013 while the cost of inpatient ALIF was $27,271 (P<0.001). CONCLUSION The findings add to the growing body of literature advocating for the utilization of ALIF in the outpatient setting for a properly selected group of patients. LEVEL OF EVIDENCE Level IV.
Collapse
|
14
|
Szadkowski M, Bahroun S, Aleksic I, Vande Kerckhove M, Ramos-Pascual S, Fière V, d'Astorg H. Clinical and radiologic outcomes of stand-alone anterior lumbar interbody fusion at L4-L5. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
15
|
Jacob KC, Patel MR, Ribot MA, Parsons AW, Vanjani NN, Pawlowski H, Prabhu MC, Singh K. Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion versus Anterior Lumbar Interbody Fusion with Posterior Instrumentation at L5/S1. World Neurosurg 2021; 157:e111-e122. [PMID: 34610449 DOI: 10.1016/j.wneu.2021.09.108] [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: 08/18/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and anterior lumbar interbody fusion (ALIF) at L5/S1. METHODS Primary, elective, single, MIS-TLIF, or ALIF with posterior fixation at L5/S1 were identified. Patient-reported outcome measures (PROMs) were collected. Coarsened exact matching was used to control for significant differences. Achievement of minimum clinically important difference [MCID] was determined by comparing ΔPROM scores with threshold values. Demographic/perioperative characteristics were compared between MIS-TLIF and ALIF cohorts using χ2 Student t tests. Differences in mean PROM scores, MCID rates, and postoperative complications were evaluated using an unpaired t test. RESULTS After coarsened exact matching, 93 patients received MIS-TLIF and 50 received ALIF. Cohorts differed in operative time, estimated blood loss, and postoperative narcotic consumption on postoperative day 0 (P < 0.034, all). Mean PROMs differed significantly on 12-Item Short-Form Physical Component Summary at 6 weeks and 1 year, Patient-Reported Outcomes Measurement Information System Physical Function at 6 weeks, Oswestry Disability Index at 6 weeks, and visual analog scale (VAS) back at 6 weeks, with the ALIF cohort showing significantly improved mean PROMs (P ≤ 0.044, all). Significantly greater rates were reported of MCID achievement for PROMs for the ALIF cohort: VAS back at 6 weeks, Oswestry Disability Index at 12 weeks, 12-Item Short-Form Physical Component Summary at 6 weeks, and Patient-Reported Outcomes Measurement Information System Physical Function at 12 weeks (P ≤ 0.047, all). A greater rate of MCID achievement for the MIS-TLIF cohort was seen for 6-week and overall VAS leg (P < 0.046, all). Postoperative fever was greater in the TLIF cohort (9.6% vs. 2.0%; P < 0.047). CONCLUSIONS Patients undergoing ALIF showed significantly improved rates of MCID achievement for disability, physical function, and back pain during the early postoperative period. However, the overall MCID achievement rate for leg pain was higher for the MIS-TLIF cohort.
Collapse
Affiliation(s)
- Kevin C Jacob
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Madhav R Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Max A Ribot
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander W Parsons
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Nisheka N Vanjani
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Hanna Pawlowski
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael C Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
| |
Collapse
|
16
|
Vargas-Moreno A, Diaz-Orduz R, Berbeo-Calderón M. Venous anatomy of the lumbar region applied to anterior lumbar interbody fusion (ALIF): Proposal of a new classification. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 7:100078. [PMID: 35141643 PMCID: PMC8820002 DOI: 10.1016/j.xnsj.2021.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
Background Anterior lumbar interbody fusion (ALIF) is a good alternative for the surgical treatment of lumbar degenerative disc disease. The primary vascular complications regarding this intervention involve the common iliac vein bifurcation complex (CIVC). Currently, no classification system allows defining which patients are more prone to these complications. We aimed to perform a retrospective study evaluating the anatomy of the common iliac CIVC at the L5-S1 disc proposing a novel classification system as it relates to the ALIF difficulty. Methods 91 consecutive patients who underwent ALIF at the L5-S1 level were included. We categorize the CIVC at the L5-S1 disc space into four types according to the veins position along the disc space. The patient records were reviewed for demographic information, surgical characteristics, and complications. The surgical difficulty was rated at the end of the procedure. Results 54% of the patients were women. The mean age was 52.5 ± 14.8 years. Mean surgical bleeding was 152 ml (range 20ml -3000 ml), and mean surgical time was 79 ± 13.3 minutes. Berbeo-Diaz-Vargas (BDV) classification type 4 was found in 43.9% of the patients. The surgical complexity was associated with the bleeding magnitude and surgical time spent (p<0.01), not being related to the corporal mass index or sacral slope. Bleeding magnitude, surgical time, and surgical complexity were significantly related to the BDV classification system (p<0.01). Weighted Cohen´s kappa index for the BDV scale was 0.89 (95% IC 0.822 – 0.974). Conclusions BDV scale is a reliable and reproducible tool for the classification of CIVC significantly related to a higher incidence of bleeding, prolonged operating time, and increased perceived difficulty by the surgeon.
Collapse
Affiliation(s)
- Alejandro Vargas-Moreno
- Corresponding author at: Neurosurgery Department, Hospital Universitario San Ignacio,Cra.7 #40- 62, Bogotá, Colombia.
| | | | | |
Collapse
|
17
|
Dowlati E, Alexander H, Voyadzis JM. Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5-S1: case series and review of the literature. Neurosurg Focus 2021; 49:E7. [PMID: 32871560 DOI: 10.3171/2020.6.focus20315] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nerve root injuries associated with anterior lumbar interbody fusion (ALIF) are uncommonly reported in the literature. This case series and review aims to describe the etiology of L5 nerve root injury following ALIF at L5-S1. METHODS The authors performed a single-center retrospective review of prospectively collected data of patients who underwent surgery between 2017 and 2019 who had postoperative L5 nerve root injuries after stand-alone L5-S1 ALIF. They also reviewed the literature with regard to nerve root injuries after ALIF procedures. RESULTS The authors report on 3 patients with postoperative L5 radiculopathy. All 3 patients had pain that improved. Two of the 3 patients had a neurological deficit, one of which improved. CONCLUSIONS Stretch neuropraxia from overdistraction is an important cause of postoperative L5 radiculopathy after L5-S1 ALIF. Judicious use of implants and careful preoperative planning to determine optimal implant sizes are paramount.
Collapse
Affiliation(s)
- Ehsan Dowlati
- 1Department of Neurosurgery, MedStar Georgetown University Hospital; and
| | | | - Jean-Marc Voyadzis
- 1Department of Neurosurgery, MedStar Georgetown University Hospital; and
| |
Collapse
|
18
|
Transforaminal Lumbar Interbody Fusion (TLIF) versus Oblique Lumbar Interbody Fusion (OLIF) in Interbody Fusion Technique for Degenerative Spondylolisthesis: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:life11070696. [PMID: 34357068 PMCID: PMC8305484 DOI: 10.3390/life11070696] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 01/03/2023] Open
Abstract
Preoperative pathology requiring fusion surgery has a great impact on postoperative outcomes. However, the previous clinical and meta-analysis studies did not control for the pathology. In this systematic review, the authors aimed to compare oblique lumbar interbody fusion (OLIF) with transforaminal interbody fusion (TLIF) as an interbody fusion technique in lumbar fusion surgery for patients with degenerative spondylolisthesis (DS). We systematically searched for relevant articles in the available databases. Among the 3022 articles, three studies were identified and met the inclusion criteria. In terms of radiological outcome, the amount of disc height restoration was greater in the OLIF group than in the TLIF group, but there was no significant difference between the two surgical techniques (p = 0.18). In the clinical outcomes, the pain improvement was not significantly different between the two surgical techniques. In terms of surgical outcomes, OLIF resulted in a shorter length of hospital stay and less blood loss than TLIF (p < 0.0001 and p = 0.02, respectively). The present meta-analysis indicated no significant difference in clinical, radiological outcomes, and surgical time between TLIF and OLIF for DS, but the lengths of hospital stay and blood loss were better in OLIF than TLIF. Though encouraging, these findings were based on low-quality evidence from a small number of retrospective studies that are prone to bias.
Collapse
|
19
|
Is postoperative atelectasis following lumbar fusion more prevalent among patients with chronic opioid use? Clin Neurol Neurosurg 2020; 199:106308. [PMID: 33069928 DOI: 10.1016/j.clineuro.2020.106308] [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: 09/10/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Chronic opioid use (COU) remains on the rise globally, acting as a marker for patient morbidity and a risk factor for adverse health outcomes. Opioid use is a risk factor for respiratory depression, which may lead to dysfunctional breathing, a known cause of atelectasis. The objective of this study was to determine whether COU is associated with increased rates of postoperative atelectasis among patients undergoing lumbar fusion. MATERIALS & METHODS Three State Inpatient Databases were used to identify patients who underwent an elective lumbar fusion through an anterior, posterior or circumferential approach in Florida, Kentucky and New York between 2013-2015. Patients with COU and those with postoperative atelectasis were identified using ICD diagnosis codes. Three operative groups were created and subsequently matched using propensity scores in order to provide comparable cohorts for analysis. Three-to-one propensity score matching was conducted using the variables of age, sex, race, number of chronic diagnoses and geographic state of admission. Multivariable logistic regressions were used to examine the relationship between COU and postoperative atelectasis. RESULTS A total of 3618 lumbar fusions were identified. Atelectasis was noted in 1.33 % of NCOU patients and 2.32 % of COU patients. On multivariable analysis, while controlling for the Elixhauser Mortality Index and patient insurance status, COU was significantly associated with atelectasis in posterior lumbar fusion (OR = 2.27; CI: 1.09-4.72; p = 0.028) and circumferential lumbar fusion (OR = 4.68; CI: 1.52-14.45; p = 0.007). The Elixhauser Mortality Index was also significantly associated with atelectasis in posterior lumbar fusion (OR = 1.08; CI: 1.04-1.11; p < 0.001) and circumferential lumbar fusion (OR = 1.09; CI: 1.03-1.16; p = 0.002). CONCLUSION Higher rates of postoperative atelectasis were found among patients with COU following posterior and circumferential lumbar fusions. The Elixhauser Mortality Index was also independently associated with atelectasis. Knowledge of these risks may allow for earlier identification and intervention in patients who are at risk.
Collapse
|
20
|
Kim YH, Ha KY, Rhyu KW, Park HY, Cho CH, Kim HC, Lee HJ, Kim SI. Lumbar Interbody Fusion: Techniques, Pearls and Pitfalls. Asian Spine J 2020; 14:730-741. [PMID: 33108838 PMCID: PMC7595814 DOI: 10.31616/asj.2020.0485] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/11/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an effective and popular surgical procedure for the management of various spinal pathologies, especially degenerative diseases. Currently, LIF can be performed with posterior, transforaminal, anterior, and lateral approaches by open surgery or minimally invasive surgery (MIS). Each technique has its own advantages and disadvantages. In general, posterior LIF is a well-established procedure with good fusion rates and low complication rates but is limited by the possibility of iatrogenic injury to the neural structures and paraspinal muscles. Transforaminal LIF is frequently performed using an MIS technique and has an advantage of reducing these iatrogenic injuries. Anterior LIF (ALIF) can restore the disk height and sagittal alignment but has inherent approach-related challenges such as visceral and vascular complications. Lateral LIF and oblique LIF are performed using an MIS technique and have shown postoperative outcomes similar to ALIF; however, these approaches carry a risk of injury to psoas, lumbar plexus, and vascular structures. Herein, we provide a detailed description of the surgical procedures of each LIF technique. We shall then consider the pearls and pitfalls, as well as propose surgical indications and contraindications based on the available evidence in the literatures.
Collapse
Affiliation(s)
- Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyung-Youl Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Hee Cho
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hun-Chul Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
21
|
Xi Z, Burch S, Mummaneni PV, Mayer RR, Eichler C, Chou D. The effect of obesity on perioperative morbidity in oblique lumbar interbody fusion. J Neurosurg Spine 2020; 33:203-210. [PMID: 32217805 DOI: 10.3171/2020.1.spine191131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Obese patients have been shown to have longer operative times and more complications from surgery. However, for obese patients undergoing minimally invasive surgery, these differences may not be as significant. In the lateral position, it is thought that obesity is less of an issue because gravity pulls the visceral fat away from the spine; however, this observation is primarily anecdotal and based on expert opinion. The authors performed oblique lumbar interbody fusion (OLIF) and they report on the perioperative morbidity in obese and nonobese patients. METHODS The authors conducted a retrospective review of patients who underwent OLIF performed by 3 spine surgeons and 1 vascular surgeon at the University of California, San Francisco, from 2013 to 2018. Data collected included demographic variables; approach-related factors such as operative time, blood loss, and expected temporary approach-related sequelae; and overall complications. Patients were categorized according to their body mass index (BMI). Obesity was defined as a BMI ≥ 30 kg/m2, and severe obesity was defined as a BMI ≥ 35 kg/m2. RESULTS There were 238 patients (95 males and 143 females). There were no significant differences between the obese and nonobese groups in terms of sex, levels fused, or smoking status. For the entire cohort, there was no difference in operative time, blood loss, or complications when comparing obese and nonobese patients. However, a subset analysis of the 77 multilevel OLIFs that included L5-S1 demonstrated that the operative times for the nonobese group was 223.55 ± 57.93 minutes, whereas it was 273.75 ± 90.07 minutes for the obese group (p = 0.004). In this subset, the expected approach-related sequela rate was 13.2% for the nonobese group, whereas it was 33.3% for the obese group (p = 0.039). However, the two groups had similar blood loss (p = 0.476) and complication rates (p = 0.876). CONCLUSIONS Obesity and morbid obesity generally do not increase the operative time, blood loss, approach-related sequelae, or complications following OLIF. However, obese patients who undergo multilevel OLIF that includes the L5-S1 level do have longer operative times or a higher rate of expected approach-related sequelae. Obesity should not be considered a contraindication to multilevel OLIF, but patients should be informed of potentially increased morbidity if the L5-S1 level is to be included.
Collapse
Affiliation(s)
- Zhuo Xi
- Departments of1Neurological Surgery and
- 4Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | | | | | | | - Charles Eichler
- 3Division of Vascular Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- Departments of1Neurological Surgery and
| |
Collapse
|
22
|
Verma R, Virk S, Qureshi S. Interbody Fusions in the Lumbar Spine: A Review. HSS J 2020; 16:162-167. [PMID: 32523484 PMCID: PMC7253570 DOI: 10.1007/s11420-019-09737-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height. QUESTIONS/PURPOSES We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine. METHODS Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review. RESULTS Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK-titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation. CONCLUSIONS All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.
Collapse
Affiliation(s)
- Ravi Verma
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
| | - Sohrab Virk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA
| |
Collapse
|
23
|
Malik AT, Xie J, Xi R, Yu E, Kim J, Khan SN. Risk factors for post-discharge complications and readmissions in home-discharges after elective posterior lumbar fusions. Clin Neurol Neurosurg 2019; 185:105501. [PMID: 31479871 DOI: 10.1016/j.clineuro.2019.105501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Previous literature has studied overall post-operative outcomes following lumbar fusions. We examined the rates and risk factors for adverse outcomes in patients who are being discharged home. PATIENTS AND METHODS The 2012-2016 ACS-NSQIP database was used to query for patients undergoing 1- to 2-level posterior lumbar fusions (PLFs) for degenerative spinal pathology. Patients discharged to a destination other than home were removed from the database. RESULTS Out of a total of 19,179 home-discharge patients, 546 (2.8%) experienced any adverse event (AAE), 276 experienced a severe adverse event (SAE) and 321 (1.7%) experienced a minor adverse event (MAE). Overall re-admission and re-operation rate in home-discharged patients was 4.4% and 2.5%. Multivariate analysis identified the following predictors for experiencing an AAE - Bleeding disorder (OR 2.25), BMI ≥ 35.0 vs. BMI < 25 (OR 1.96), chronic steroid use (OR 1.89), a LOS > 3 days (OR 1.53), insulin-dependent diabetes mellitus (OR 1.44), hypertension (OR 1.28) and female gender (OR 1.24). Patients with a pre-discharge complication (OR 2.12), bleeding disorders (OR 1.84), chronic steroid use (OR 1.55), age>75 (OR 1.49), age>65 (OR 1.26), history of severe COPD (OR 1.43), total operative time >210 min. (OR 1.26), ASA > II (OR 1.26) and undergoing a 2-level fusion (OR 1.21) were likely to be re-admitted from home. CONCLUSIONS Providers should utilize the data to risk-stratify and better understand the need of provision of supplemental health-care services, in home-discharged patients, and/or regular clinic follow-up to minimize the rate of adverse events and reduce costs in a bundled-payment environment.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States
| | - Jack Xie
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States
| | - Romi Xi
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States
| | - Jeffery Kim
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, United States.
| |
Collapse
|