Contribution of Lateral Interbody Fusion in Staged Correction of Adult Degenerative Scoliosis

Postoperative Radiological Improvement after Staged Surgery Using Lateral Lumbar Interbody Fusion for Preoperative Coronal Malalignment in Patients with Adult Spinal Deformity

This retrospective observational study evaluated improvement in coronal malalignment (CM) after anteroposterior staged surgery using lateral lumbar interbody fusion (LLIF) in patients with coronal lumbar curve adult spinal deformity (ASD). Sixty patients with ASD underwent surgery; 34 had SRS-Schwab type L lumbar curve. Patients with a coronal balance distance (CBD) ≥20 mm were diagnosed with CM. Using the Obeid CM classification, we classified the preoperative coronal pattern as concave CM (type 1) or convex CM (type 2). Demographic, surgical, and radiological parameters were compared. Whole-spine standing radiographs were assessed preoperatively and postoperatively. Twenty-three patients had type 1A, six had type 2A, five had no CM, and none had type 1B or 2B according to the Obeid CM classification. Compared with patients with Obeid type 1A, those with Obeid type 2A had significantly higher preoperative and postoperative coronal L4 tilts and a smaller change in corrected CBD (Δ|CBD|) (76.6 mm vs. 24.1 mm, p < 0.001). At the final follow-up, 58.6% (17/29 patients) of patients with SRS-Schwab type L CM showed improvement after corrective fusion using LLIF. Although the difference was not statistically significant, CM improved in 69.6% (16/23 patients) of patients with Obeid type 1A type but only 16.7% (1/6 patients) of those with Obeid type 2A type (p = 0.056). CM was more likely to remain after anteroposterior staged surgery using LLIF in patients with preoperative Obeid type 2A ASD.

What Are the Benefits of Lateral Lumbar Interbody Fusion on the Treatment of Adult Spinal Deformity: A Systematic Review and Meta-Analysis Deformity

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to compare the efficacy of lateral lumbar interbody fusion (LLIF) combined with posterior spinal fusion (PSF) with that of conventional PSF in the treatment of adult spinal deformity (ASD).

METHODS

A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Spinopelvic parameters, surgical data, complications, and clinical outcomes at the last follow-up were compared between patients with ASD who underwent LLIF combined with PSF (LLIF+PSF group) and those who underwent conventional PSF (only-PSF group).

RESULTS

Ten studies, comprising 621 patients with ASD (313 in the LLIF+PSF group and 308 in the only-PSF group), were included. The level of evidence was III for 7 studies and IV for 3 studies. There was no significant difference in the improvement in the visual analog scale score, systemic complication rate, and revision rate between groups. In the LLIF+PSF group, we noted a superior restoration of lumbar lordosis (weighted mean difference [WMD], 9.77; 95% confidence interval [CI] 7.10 to 12.44, P < .001), pelvic tilt (WMD, -2.50; 95% CI -4.25 to -.75, P = .005), sagittal vertical axis (WMD, -21.92; 95% CI -30.73 to -13.11, P < .001), and C7 plumb line-center sacral vertical line (WMD, -4.03; 95% CI -7.52 to -.54, P = .024); a lower estimated blood loss (WMD, -719.99; 95% CI -1105.02 to -334.96, P < .001) while a prolonged operating time (WMD, 104.89; 95% CI 49.36 to 160.43, P < .001); lower incidence of pseudarthrosis (risk ratio [RR], .26; 95% CI .08 to .79, P = .017) while higher incidence of neurologic deficits (RR, 2.04; 95% CI 1.27 to 3.25, P = .003); and a better improvement in Oswestry Disability Index score (WMD, -7.04; 95% CI -10.155 to -3.93, P < .001) and Scoliosis Research Society-22 total score (WMD, .27; 95% CI .11 to .42, P = .001). The level of evidence in this systematic review and meta-analysis was II.

CONCLUSION

Compared with conventional PSF, LLIF combined with PSF was associated with superior restoration of sagittal and coronal alignment, lower incidence of pseudarthrosis, better improvement in quality of life, and less surgical invasiveness in the treatment of ASD, albeit at the cost of prolonged surgical times and substantially high incidence of lower extremity symptoms. Surgeons should weigh the advantages and disadvantages of this procedure, and inform patients about its side effects.

Planned two-stage surgery using lateral lumbar interbody fusion and posterior corrective fusion: a retrospective study of perioperative complications

PURPOSE

To determine the effect of planned two-stage surgery using lateral lumbar interbody fusion (LLIF) on the perioperative complication rate following corrective fusion surgery in patients with kyphoscoliosis.

METHODS

Consecutive patients with degenerative scoliosis who underwent corrective fusion were divided into a control group that underwent single-stage posterior-only surgery and a group that underwent planned two-staged surgery with LLIF and posterior corrective fusion. We collected the patient background and surgical data and assessed the perioperative complication rates. We also investigated spinopelvic parameters and patient-reported outcome measurements (PROMs).

RESULTS

One hundred and thirty-eight patients of mean age 69.8 (range, 50-84) years who met the study inclusion criteria were included. The two-stage group (n = 75) underwent a staged anterior-posterior surgical procedure, and the control group (n = 63) underwent single-stage surgery. There was no significant between-group difference in the incidence of perioperative complications, except for deep wound infection (reoperation is necessary for surgical site infection). Revision surgery within 3 months of the initial surgery was more common in the control group (n = 8, 12.7%) than in the two-stage group (n = 3, 4.0%). Spinopelvic parameters and PROMs were significantly better in the two-stage group at 2 years postoperatively.

CONCLUSION

The complication rate for planned two-stage surgery was similar to that of previous posterior-only single-stage surgery. However, early reoperation was less common, and the degree of spinal correction and clinical results were significantly better after two-stage surgery.

Safety Profile, Surgical Technique, and Early Clinical Results for Simultaneous Lateral Lumbar Interbody Fusion and Anterior Lumbar Interbody Fusion in a Lateral Position

STUDY DESIGN

Description of surgical technique and retrospective review.

OBJECTIVE

To describe a novel surgical technique for multilevel lumbar fusion and describe early clinical results.

SUMMARY OF BACKGROUND DATA

Patients with multilevel lumbar spinal stenosis and adult degenerative scoliosis often require multilevel interbody placement to achieve indirect decompression and lordosis. We describe a case series of patients treated with simultaneous lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF) at L5-S1.

METHODS

We retrospectively reviewed a consecutive series of patients treated for multilevel lumbar spinal stenosis with simultaneous ALIF and LLIF with at least 3-month follow-up. All patients received supplemental percutaneous bilateral pedicle screw placement as well. We measured on preoperative radiographs their lumbar lordosis, pelvic incidence, and L5-S1 lordosis. Intraoperative factors such as operative time, estimated blood loss, fluids provided, number of levels fused, and whether a trainee was present during the procedure were all recorded.

RESULTS

There were 15 patients included within our case series (69.5, 4 F). There were no reported intraoperative vascular or neurological complications in 15 cases. The operative time for the cases ranged from 2.7 to 8.4 hours (average=5.2±1.9 h). The average lordosis gained at L5-S1 was 8.6±3.0 degrees and the average lumbar lordosis gained was 14.7±6.4 degrees. The average PI-LL mismatch went from 22.4±13.3 degrees preoperative to 7.8±10.2 degrees postoperative. One patient had a postoperative complication of a sacral fracture requiring placement of a pelvic screw for a L2-pelvis fusion. There were 8 patients with 4+ levels of fusion. For this cohort of patients, the average lumbar lordosis gained was 16.0±7.5 degrees and the average PI-LL mismatch went from 24.7±16.3 degrees preoperative to 8.8±12.9 degrees postoperative. For the patients with 4+ levels of fusion, the average operative time was 5.9±1.8 hours.

CONCLUSIONS

We have described our early positive results with simultaneous LLIF/ALIF surgery for treatment of lumbar degenerative conditions.

Limited Cost Benefit of Lateral Interbody Fusion for Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The aim of this study was to compare the utility and cost-effectiveness of multilevel lateral interbody fusion (LIF) combined with posterior spinal fusion (PSF) (L group) and conventional PSF (with transforaminal lumbar interbody fusion) (P group) in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

The clinical and radiographic outcomes of multilevel LIF for ASD have been reported favorable; however, the cost benefit of LIF in conjunction with PSF is still controversial.

METHODS

Retrospective comparisons of 88 surgically treated ASD patients with minimum 2-year follow-up from a multicenter database (L group [n = 39] and P group [n = 49]) were performed. Demographic and radiographic data, health-related quality of life (HRQoL), and the direct hospitalization cost for the initial surgery and 2-year total hospitalization cost were analyzed.

RESULTS

Analyses of sagittal spinal alignment showed no significant difference between the two groups at baseline and 2 years post-operation. Surgical time was longer in the L group (L vs. P: 354 vs. 268 minutes, P < 0.01), whereas the amount of blood loss was greater in the P group (494 vs. 678 mL, P = 0.03). The HRQoL was improved similarly at 2 years post-operation (L vs. P: SRS-22 total score, 3.86 vs. 3.80, P = 0.54), with comparable revision rates (L vs. P: 18% vs. 10%, P = 0.29). The total direct cost of index surgery was significantly higher in the L group (65,937 vs. 49,849 USD, P < 0.01), which was mainly due to the operating room cost, including implant cost (54,466 vs. 41,328 USD, P < 0.01). In addition, the 2-year total hospitalization cost, including revision surgery, was also significantly higher in the L group (70,847 vs. 52,560 USD, P < 0.01).

CONCLUSION

LIF with PSF is a similarly effective surgery for ASD when compared with conventional PSF. However, due to the significantly higher cost, additional studies on the cost-effectiveness of LIF in different ASD patient cohorts are warranted.

LEVEL OF EVIDENCE

3.

The effect of vascular approach surgeons on perioperative complications in lateral transpsoas lumbar interbody fusions

BACKGROUND CONTEXT

Lateral lumbar interbody fusion (LLIF) is a popular technique used in spine surgery. It is minimally invasive, provides indirect decompression, and allows for coronal plane deformity correction. Despite these benefits, the approach to LLIF has been linked to complications associated with the lumbosacral plexus and vascular anatomy. As a result, vascular surgeons may be recruited for the exposure portion of the procedure.

PURPOSE

The purpose of this study was to compare exposure-related complication and postoperative (postop) neuropraxia rates between exposure (EXP) and spine surgeon only (SSO) groups while performing the approach for LLIF.

STUDY DESIGN/SETTING

Retrospective analysis of patients treated at a single institution.

PATIENT SAMPLE

Patients undergoing LLIF procedures between 2012 and 2018.

OUTCOME MEASURES

Operative time, estimated blood loss, fluoroscopy, length of stay (LOS), intra- and postoperative complications, and physiologic measures including pre- and postoperative motor examinations and unresolved neuropraxia.

METHODS

Patients who underwent LLIF were separated into EXP and SSO groups based on the presence or absence of vascular/general surgeon during the approach. The entire clinical history of patients with a decrease in pre- and postop motor examination was reviewed for the presence of neuropraxia. All other intra- and postop exposure-related complications were recorded for comparison. Propensity score matching (PSM) was performed to account for age, Charlson Comorbidity Index (CCI) percentage of LLIFs including L4-L5, and number of levels fused. Independent t test and chi-square analyses were used to identify significant differences between EXP and SSO groups. Statistical significance was set at p<.05.

RESULTS

Two hundred and seventy-five patients underwent LLIF procedures, 155 SSO and 120 EXP. Postoperatively, 26 patients (11.1%) experienced a drop in any Medical Research Council (MRC) score, and two patients (0.7%) experienced unresolved quadriceps palsies. The mean recovery time for MRC scores was 84.4 days. Other complications included 2 pneumothoraces (0.7%), 1 iliac vein injury (0.4%), 14 cases of ileus (5.1%), 3 pulmonary emboli (1.1%), 2 deep vein thrombosis (0.7%), 3 cases of abdominal wall paresis (1.1%), and one abdominal hematoma (0.4%). After PSM, demographics including age, gender, body mass index, CCI, levels fused, and operative time were similar between cohorts. Twenty patients had changes in pre- to postop motor scores (SSO 9.4%, EXP 12.4%, p>.05). Iliopsoas motor scores decreased at the highest rate (EXP 12.4%, SSO 8.2%, p>.05) followed by quadriceps (EXP 5.2%, SSO 4.7%, p>.05). One SSO patient's postop course was complicated by a foot drop but returned to baseline within 1 year. One patient in EXP group developed an unresolved quadriceps palsy (EXP 1.0%, SSO 0.0%, p>.05). Intraoperative exposure complications included one pneumothorax (EXP 1.0%, SSO 0.0%, p>.05). There were no differences in PE/DVT, Ileus, or LOS. In the EXP cohort, three patients experienced abdominal wall paresis (EXP 2.9%, SSO 0.00%, p=.246).

CONCLUSIONS

Comparing the LLIF exposures performed by EXP and SSO, we found no significant difference in the rates of complications. Additional research is needed to determine the etiology of the abdominal wall complications. In conclusion, neuropraxia- and approach-related complications are similarly low between exposure and spine surgeons.