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Johnson SE, Michalopoulos GD, Flanigan PM, Katsos K, Ibrahim S, Freedman BA, Bydon M. Interbody cages versus structural bone grafts in lumbar arthrodesis: a systematic review and meta-analysis. J Neurosurg Spine 2024:1-11. [PMID: 38728766 DOI: 10.3171/2024.2.spine23940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/22/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE The role of interbodies in lumbar arthrodesis has been insufficiently supported by evidence, impacting clinical decision-making and occasionally insurance coverage. This study aimed to compare clinical and radiological outcomes between lumbar arthrodesis with a synthetic interbody spacer (cage) versus structural bone graft alone (autograft or allograft) in patients with degenerative spine disease. METHODS A systematic review of the literature was performed to identify studies directly comparing outcomes of lumbar interbody arthrodesis with and without interbody cage use. The outcomes of individual studies were synthesized in meta-analyses using random-effects models. RESULTS Twenty studies with 1508 patients (769 with an interbody cage and 739 without an interbody cage) were included. Interbody cage placement was associated with a significantly greater increase in disc height after surgery (4.0 mm vs 3.4 mm, p < 0.01). There was a significantly greater reduction of back pain (visual analog scale [VAS] score) in cases in which an interbody cage was used (5.4 vs 4.7, p = 0.03). Fusion rates were 5.5% higher in the cage group (96.3% vs 90.8%) and reached statistical significance (p = 0.03). No statistically significant differences were identified between the two groups regarding all-cause reoperation rates, complication rates, or improvement in Oswestry Disability Index score or leg pain (VAS score). CONCLUSIONS These results suggest that implantation of an interbody cage is associated with higher rates of fusion, more effective maintenance of disc height, and greater improvement of back pain. This study underlines the clinical value of interbody cages in lumbar arthrodesis for patients with degenerative spine disease.
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Affiliation(s)
- Sarah E Johnson
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Giorgos D Michalopoulos
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Patrick M Flanigan
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Konstantinos Katsos
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sufyan Ibrahim
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- Departments of1Neurologic Surgery and
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Bui AT, Le H, Hoang TT, Trinh GM, Shao HC, Tsai PI, Chen KJ, Hsieh KLC, Huang EW, Hsu CC, Mathew M, Lee CY, Wang PY, Huang TJ, Wu MH. Development of End-to-End Artificial Intelligence Models for Surgical Planning in Transforaminal Lumbar Interbody Fusion. Bioengineering (Basel) 2024; 11:164. [PMID: 38391650 PMCID: PMC10885900 DOI: 10.3390/bioengineering11020164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/01/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
Transforaminal lumbar interbody fusion (TLIF) is a commonly used technique for treating lumbar degenerative diseases. In this study, we developed a fully computer-supported pipeline to predict both the cage height and the degree of lumbar lordosis subtraction from the pelvic incidence (PI-LL) after TLIF surgery, utilizing preoperative X-ray images. The automated pipeline comprised two primary stages. First, the pretrained BiLuNet deep learning model was employed to extract essential features from X-ray images. Subsequently, five machine learning algorithms were trained using a five-fold cross-validation technique on a dataset of 311 patients to identify the optimal models to predict interbody cage height and postoperative PI-LL. LASSO regression and support vector regression demonstrated superior performance in predicting interbody cage height and postoperative PI-LL, respectively. For cage height prediction, the root mean square error (RMSE) was calculated as 1.01, and the model achieved the highest accuracy at a height of 12 mm, with exact prediction achieved in 54.43% (43/79) of cases. In most of the remaining cases, the prediction error of the model was within 1 mm. Additionally, the model demonstrated satisfactory performance in predicting PI-LL, with an RMSE of 5.19 and an accuracy of 0.81 for PI-LL stratification. In conclusion, our results indicate that machine learning models can reliably predict interbody cage height and postoperative PI-LL.
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Affiliation(s)
- Anh Tuan Bui
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Spine Surgery, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Hieu Le
- School of Computer and Communication Sciences, Swiss Federal Institute of Technology in Lausanne, 1015 Lausanne, Switzerland
| | - Tung Thanh Hoang
- Department of Spine Surgery, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Giam Minh Trinh
- Department of Trauma-Orthopedics, College of Medicine, Pham Ngoc Thach Medical University, Ho Chi Minh City 700000, Vietnam
- Department of Pediatric Orthopedics, Hospital for Traumatology and Orthopedics, Ho Chi Minh City 700000, Vietnam
| | - Hao-Chiang Shao
- Institute of Data Science and Information Computing, National Chung Hsing University, Taichung City 402, Taiwan
| | - Pei-I Tsai
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu 31057, Taiwan
| | - Kuan-Jen Chen
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu 31057, Taiwan
| | - Kevin Li-Chun Hsieh
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Research Center of Translational Imaging, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - E-Wen Huang
- Department of Materials Science and Engineering, National Yang Ming Chiao Tung University, Hsinchu 30013, Taiwan
| | - Ching-Chi Hsu
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei 106, Taiwan
| | - Mathew Mathew
- Department of Biomedical Engineering, Colleges of Engineering and Medicine, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Ching-Yu Lee
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Po-Yao Wang
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Tsung-Jen Huang
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- TMU Biodesign Center, Taipei Medical University, Taipei 11031, Taiwan
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Zavras AG, Federico V, Nolte MT, Butler AJ, Dandu N, Munim M, Harper DE, Lopez GD, DeWald CJ, An HS, Singh K, Phillips FM, Colman MW. Risk Factors for Subsidence Following Anterior Lumbar Interbody Fusion. Global Spine J 2024; 14:257-264. [PMID: 35593712 PMCID: PMC10676155 DOI: 10.1177/21925682221103588] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Anterior lumbar interbody fusion (ALIF) may be complicated by subsidence, which can lead to significant morbidity including pain, disc space collapse, neural compression, segmental kyphosis, instability, and vertebral body fracture. This study sought to identify patient and procedural risk factors for subsidence in patients undergoing ALIF. METHODS This study analyzed consecutive patients who underwent ALIF at a single institution with a minimum of 2 years follow-up. Patients were grouped as either Non-Subsidence (NS-ALIF) or Cage Subsidence (CS-ALIF) based on the final postoperative radiograph. Demographic variables, operative characteristics, and radiographic outcomes were evaluated to identify significant predictors on univariate and multivariate statistics. RESULTS 144 patients (170 levels) were included with an average follow-up of 50.70 ± 28.44 months (4.23 years). The incidence of subsidence was 22.94% (39/170 levels). On univariate statistics, the CS-ALIF group was significantly older (P = .020), had higher BMI (P = .048), worse ASA (P = .001), higher prevalence of comorbid osteoporosis (P < .001), and a more anteriorly placed interbody device (P = .005). On multivariate analysis, anterior cage placement remained the only significant predictor (OR: 1.08, 95% CI: 1.03-1.14; P = .003). There was a significantly higher rate of subsequent adjacent segment surgery among the CS-ALIF group (P = .035). CONCLUSION Factors contributing to subsidence in ALIF included older age, higher BMI, severe ASA, and osteoporosis, while anterior cage placement remained the only independent predictor on multivariate analysis. Subsidence was associated with a higher rate of subsequent adjacent segment surgery. Surgical technique should optimize placement of the interbody cage and avoid overstuffing the disc space.
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Affiliation(s)
- Athan G. Zavras
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent Federico
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael T. Nolte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alexander J. Butler
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Navya Dandu
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Mohammed Munim
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Daniel E. Harper
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory D. Lopez
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Howard S. An
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Frank M. Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew W. Colman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Alhammoud A, Korytkowski PD, Lavelle WF, Tallarico RA. The Outcomes of Revision Anterior Cervical Decompression and Fusion Using a Stand-Alone Implant Versus Traditional Interbody Polyetheretherketone Cage, Titanium Plate, and Screw Instrumentation. Cureus 2023; 15:e49246. [PMID: 38143630 PMCID: PMC10739182 DOI: 10.7759/cureus.49246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
INTRODUCTION Anterior cervical decompression and fusion (ACDF) is the standard surgical procedure for cervical radiculopathy and myelopathy, although ACDF includes risks of adjacent segment disease (ASD) and subsequent revision procedures. Various interbody cage, plate, and screw options can be utilized. Stand-alone devices were designed to overcome undesired complications of hardware prominence and associated dysphagia, soft tissue violation, and adjacent level encroachment. Implants include biomechanical structural support (cage) composed of various materials (polyetheretherketone (PEEK)/titanium) and integral fixation (screws/blades). The purpose was to compare intraoperative, short- and long-term outcomes of revision ACDF using a stand-alone implant (ACDF-ZP group) versus traditional interbody PEEK cage, titanium plate, and screw instrumentation (ACDF-CP group). METHODS This was a retrospective, cohort study reviewing charts of patients who underwent revision ACDF. The primary outcome measure was the incidence of postoperative dysphagia. Secondary outcomes included intraoperative, short-term, and long-term outcomes and complications. RESULTS Sixty-one patients were included (ACDF-ZP group = 50; ACDF-CP group = 11). In-hospital incidence of dysphagia was significantly less in the ACDF-CP group (P = 0.041). Thrity-one (62.0%) of the ACDF-ZP group reported dysphagia postoperatively, half resolved by 6 weeks, and two persisted for more than 6 months. Five (45.5%) of the ACDF-CP group reported dysphagia with most resolving within 6 weeks. There were no statistically significant differences between groups in short- or long-term complications, dysphonia, or reoperation rates. No statistical significance was seen in blood loss, operative time, hospital stay, local and global alignment, or cage subsidence. CONCLUSION Rates of dysphagia were comparable between groups at short and long-term follow-up, despite a greater incidence of postoperative dysphagia in the ACDF-ZP group. All complications and occurrences of cage subsidence were observed in the ACDF-ZP group, which may be attributed to the larger sample size. Given these findings, zero-profile stand-alone implants and traditional interbody PEEK cage, titanium plate, and screw instrumentation appear to be both safe and effective options for revision ACDF.
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Affiliation(s)
| | - Paul D Korytkowski
- Orthopedic Surgery, State University of New York Upstate Medical University, Syracuse, USA
| | - William F Lavelle
- Orthopedic Surgery, State University of New York Upstate Medical University, Syracuse, USA
| | - Richard A Tallarico
- Orthopedic Surgery, State University of New York Upstate Medical University, Syracuse, USA
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Kotheeranurak V, Jitpakdee K, Lin GX, Mahatthanatrakul A, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim JS. Subsidence of Interbody Cage Following Oblique Lateral Interbody Fusion: An Analysis and Potential Risk Factors. Global Spine J 2023; 13:1981-1991. [PMID: 34920690 PMCID: PMC10556923 DOI: 10.1177/21925682211067210] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES This study aimed to report the incidence and potential risk factors of polyetheretherketone (PEEK) cage subsidence following oblique lateral interbody fusion (OLIF) for lumbar degenerative diseases. We proposed also an algorithm to minimize subsidence following OLIF surgery. METHODS The study included a retrospective cohort of 107 consecutive patients (48 men and 59 women; mean age, 67.4 years) who had received either single- or multi-level OLIF between 2012 and 2019. Patients were classified into subsidence and non-subsidence groups. PEEK cage subsidence was defined as any violation of either endplate from the computed tomography scan in both sagittal and coronal views. Preoperative variables such as age, sex, body mass index, bone mineral density (BMD) measured by preoperative dual-energy X-ray absorptiometry, smoking status, corticosteroid use, diagnosis, operative level, multifidus muscle cross-sectional area, and multifidus muscle fatty degeneration were collected. Age-related variables (height and length) were also documented. Univariate and multivariate logistic regression analyses were used to analyze the risk factors of subsidence. RESULTS Of the 107 patients (137 levels), 50 (46.7%) met the subsidence criteria. Higher PEEK cage height had the strongest association with subsidence (OR = 9.59, P < .001). Other factors significantly associated with cage subsistence included age >60 years (OR = 3.15, P = .018), BMD <-2.5 (OR = 2.78, P = .006), and severe multifidus muscle fatty degeneration (OR = 1.97, P = .023). CONCLUSIONS Risk factors for subsidence in OLIF were age >60 years, BMD < -2.5, higher cage height, and severe multifidus muscle fatty degeneration. Patients who had subsidence had worse early (3 months) postoperative back and leg pain.
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Affiliation(s)
- Vit Kotheeranurak
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Khanathip Jitpakdee
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, PR China
| | | | - Weerasak Singhatanadgige
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Worawat Limthongkul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Jin-Sung Kim
- Spine Center, Department of Neurosurgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Cheng CH, Chiu PY, Chen HB, Niu CC, Nikkhoo M. The influence of over-distraction on biomechanical response of cervical spine post anterior interbody fusion: a comprehensive finite element study. Front Bioeng Biotechnol 2023; 11:1217274. [PMID: 37650042 PMCID: PMC10464836 DOI: 10.3389/fbioe.2023.1217274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/04/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction: Anterior cervical discectomy and fusion (ACDF) has been considered as the gold standard surgical treatment for cervical degenerative pathologies. Some surgeons tend to use larger-sized interbody cages during ACDF to restore the index intervertebral disc height, hence, this study evaluated the effect of larger-sized interbody cages on the cervical spine with ACDF under both static and cyclic loading. Method: Twenty pre-operative personalized poro-hyperelastic finite element (FE) models were developed. ACDF post-operative models were then constructed and four clinical scenarios (i.e., 1) No-distraction; 2) 1 mm distraction; 3) 2 mm distraction; and 4) 3 mm distraction) were predicted for each patient. The biomechanical responses at adjacent spinal levels were studied subject to static and cyclic loading. Non-parametric Friedman statistical comparative tests were performed and the p values less than 0.05 were reflected as significant. Results: The calculated intersegmental range of motion (ROM) and intradiscal pressure (IDP) from 20 pre-operative FE models were within the overall ranges compared to the available data from literature. Under static loading, greater ROM, IDP, facet joint force (FJF) values were detected post ACDF, as compared with pre-op. Over-distraction induced significantly higher IDP and FJF in both upper and lower adjacent levels in extension. Higher annulus fibrosus stress and strain values, and increased disc height and fluid loss at the adjacent levels were observed in ACDF group which significantly increased for over-distraction groups. Discussion: it was concluded that using larger-sized interbody cages (the height of ≥2 mm of the index disc height) can result in remarkable variations in biomechanical responses of adjacent levels, which may indicate as risk factor for adjacent segment disease. The results of this comprehensive FE investigation using personalized modeling technique highlight the importance of selecting the appropriate height of interbody cage in ACDF surgery.
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Affiliation(s)
- Chih-Hsiu Cheng
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ping-Yeh Chiu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hung-Bin Chen
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Chien Niu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Mohammad Nikkhoo
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
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Fushimi K, Miyagawa T, Iwai C, Nozawa S, Iinuma N, Tanaka R, Shirai G, Tanahashi H, Yokoi T, Akiyama H. Transforaminal Lumbar Interbody Fusion with Double Banana Cages: Clinical Evaluations and Finite Element Model Analysis. Global Spine J 2023:21925682231165709. [PMID: 36944178 DOI: 10.1177/21925682231165709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
STUDY DESIGN Clinical and basic study. OBJECTIVES This study aimed to investigate whether transforaminal lumbar interbody fusion (TLIF) using 2 banana-shaped cages leads to good clinical outcomes. METHODS First, we conducted a clinical study to compare outcomes among patients who underwent TLIF using different types or numbers of cages. Propensity matched patients in each group were reviewed. Thirty-four patients who underwent surgery with 2 bullet-shaped cages (group A), 34 with a banana-shaped cage (group B), and 34 with 2 banana-shaped cages (group C) were compared. Twelve months after the surgery, bony fusion and cage subsidence were evaluated. RESULTS The mean amount of cage subsidence was 14.9% in group A, 19.9% in group B, and 11.8% in group C. Subsidence in group B was significantly greater than that in group C (P < .01). Radiological bony fusion was not achieved in 2 cases in group B. Second, we performed a finite element model (FEM) analysis to determine the biomechanical stress of the vertebral endplate by comparing the single-banana cage construct with a double banana-shaped cage construct. FEM analysis showed that the maximum stress of the endplate in the single-cage model was 1.72-times greater than the maximum stress in the double-cage model. Furthermore, the maximal stress in the single-cage model was significantly higher than in the double-cage model during lumbar extension and side bending. CONCLUSION This study showed that TLIF with double banana-shaped cages led to good clinical outcomes with less cage subsidence, probably because of decreased mechanical stress on the vertebral endplate.
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Affiliation(s)
- Kazunari Fushimi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takaki Miyagawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chizuo Iwai
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Nozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuki Iinuma
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ryo Tanaka
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Goshi Shirai
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hiroyuki Tanahashi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tatsuo Yokoi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Guyer RD, Zigler JE, Blumenthal SL, Shellock JL, Ohnmeiss DD. Evaluation of Anterior Lumbar Interbody Fusion Performed Using a Stand-Alone, Integrated Fusion Cage. Int J Spine Surg 2023; 17:1-5. [PMID: 35940637 PMCID: PMC10025836 DOI: 10.14444/8354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Anterior lumbar interbody fusion (ALIF) has been performed for many years. Often, posterior supplemental fixation has been used to provide additional stability to the operated segment. Interbody implants have evolved to incorporate unique designs, polyetheretherketone, integrated screws, and surface texture. With these changes, the need for supplemental posterior fixation has been debated. The purpose of this study was to evaluate the clinical outcome of stand-alone ALIF. METHODS A surgery log was reviewed to identify the consecutive series of 58 patients undergoing ALIF using a STALIF stand-alone cage from March 2011 (first case) to December 2018 (minimum 24 months postoperative) with a mean follow-up of 30.6 months. All patients were treated for symptomatic degenerative conditions. Charts were reviewed to collect general patient information, operative data, and patient-reported outcomes, including the Oswestry Disability Index (ODI), visual analog scales (VAS) separately assessing back pain and leg pain, and re-operations. For patients who were not seen recently in clinic for follow-up, current outcome data were collected through mailings. RESULTS The mean operative blood loss was 52.1 mL. There was a statistically significant improvement in mean ODI scores from 41.7 preoperatively to 21.0 at follow-up (P < 0.01). There was also significant improvement (P < 0.01) in VAS back pain (6.0-2.5) and leg pain (4.1-1.3). Subsequent surgery was performed on 9 patients. Reasons for re-operation were pseudoarthrosis (n = 3), progressive cage subsidence (n = 1), foraminal stenosis at the index level (n = 1), metal allergy reaction (n = 2), adjacent segment degeneration (n = 1), and ongoing pain (n = 1). There were no cases of device failure, vertebral body fracture, or screws backing out of the implant. DISCUSSION Stand-alone ALIF was associated with statistically significant improvements in ODI scores, back pain, and leg pain. The re-operation rate for clear pseudoarthrosis or cage subsidence was 6.8%. These results support that stand-alone ALIF produces good outcomes in patients treated for symptomatic disc degeneration while avoiding the use of posterior fixation and its complication risk and cost. CLINICAL RELEVANCE The results of this study support that stand-alone ALIF is a viable procedure for the treatment of symptomatic disc degeneration unresponsive in patients who have failed nonoperative care and who do not have specific indications for supplemental posterior instrumentation. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Richard D Guyer
- Center for Disc Replacement at Texas Back Institute, Plano, TX, USA
| | - Jack E Zigler
- Center for Disc Replacement at Texas Back Institute, Plano, TX, USA
| | | | | | - Donna D Ohnmeiss
- Center for Disc Replacement at Texas Back Institute, Plano, TX, USA
- Texas Back Institute Research Foundation, Plano, TX, USA
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9
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Tadokoro N, Kiyasu K, Aoyama N, Mizobuchi S, Ikeuchi M, Kida K, Tani T, Kasai Y. A comparison of reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) between the procedures with and without anterior plate fixation. J Med Invest 2023; 70:334-342. [PMID: 37940516 DOI: 10.2152/jmi.70.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
INTRODUCTION The plate fixation for anterior cervical discectomy and fusion (ACDF) has become increasingly widespread for facilitating early mobilization and improving fusion rate. However, apart from multilevel operations, there is still some controversy over its use for single-level ACDF. This retrospective study has compared the reoperation rates after single-level ACDFs performed at our institution between the procedures with and without plate fixation. METHODS This retrospective study included a total of 131 patients with???1-year of follow-up after a single-level ACDF, consisting of 100 patients without plating (conventional ACDF) and 31 patients with plate fixation (plated ACDF). RESULTS Eleven patients (8.4% of all patients):four conventional ACDFs (4% of the conventional ACDFs) and seven plated ACDFs (22.6% of the plated ACDFs), had reoperation surgeries. The incidence of reoperation was significantly higher in the plated ACDFs than in the conventional ACDFs (P=0.0037). The log-rank test revealed a significant difference (P=0.00003) in 5-year reoperation-free survival rates between the conventional (96.9%) and the plated groups (68.3%). CONCLUSION Anterior cervical plating may have a negative impact on the adjacent segment integrity, resulting in an increased reoperation rate after a single-level ACDF at relatively shorter postoperative time points. J. Med. Invest. 70 : 334-342, August, 2023.
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Affiliation(s)
- Nobuaki Tadokoro
- Department of Orthopaedic Surgery, Kochi University, Kochi, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi University, Kochi, Japan
| | - Naoki Aoyama
- Department of Orthopaedic Surgery, Kochi University, Kochi, Japan
| | - Shuhei Mizobuchi
- Department of Orthopaedic Surgery, Kochi University, Kochi, Japan
| | - Masahiko Ikeuchi
- Department of Orthopaedic Surgery, Kochi University, Kochi, Japan
| | - Kazunobu Kida
- Department of Orthopaedic Surgery, Kubokawa Hospital, Kochi, Japan
| | - Toshikazu Tani
- Department of Orthopaedic Surgery, Kubokawa Hospital, Kochi, Japan
| | - Yusuke Kasai
- Department of Orthopaedic Surgery, Kochi Prefectural Hata Kenmin Hospital, Kochi, Japan
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Wang R, Wu Z. Recent advancement in finite element analysis of spinal interbody cages: A review. Front Bioeng Biotechnol 2023; 11:1041973. [PMID: 37034256 PMCID: PMC10076720 DOI: 10.3389/fbioe.2023.1041973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Finite element analysis (FEA) is a widely used tool in a variety of industries and research endeavors. With its application to spine biomechanics, FEA has contributed to a better understanding of the spine, its components, and its behavior in physiological and pathological conditions, as well as assisting in the design and application of spinal instrumentation, particularly spinal interbody cages (ICs). IC is a highly effective instrumentation for achieving spinal fusion that has been used to treat a variety of spinal disorders, including degenerative disc disease, trauma, tumor reconstruction, and scoliosis. The application of FEA lets new designs be thoroughly "tested" before a cage is even manufactured, allowing bio-mechanical responses and spinal fusion processes that cannot easily be experimented upon in vivo to be examined and "diagnosis" to be performed, which is an important addition to clinical and in vitro experimental studies. This paper reviews the recent progress of FEA in spinal ICs over the last six years. It demonstrates how modeling can aid in evaluating the biomechanical response of cage materials, cage design, and fixation devices, understanding bone formation mechanisms, comparing the benefits of various fusion techniques, and investigating the impact of pathological structures. It also summarizes the various limitations brought about by modeling simplification and looks forward to the significant advancement of spine FEA research as computing efficiency and software capabilities increase. In conclusion, in such a fast-paced field, the FEA is critical for spinal IC studies. It helps in quantitatively and visually demonstrating the cage characteristics after implanting, lowering surgeons' learning costs for new cage products, and probably assisting them in determining the best IC for patients.
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Affiliation(s)
- Ruofan Wang
- Guangzhou Key Laboratory of Spine Disease Prevention and Treatment, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zenghui Wu
- Guangzhou Key Laboratory of Spine Disease Prevention and Treatment, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- *Correspondence: Zenghui Wu,
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12
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Li G, Yang L, Wu G, Qian Z, Li H. An update of interbody cages for spine fusion surgeries: from shape design to materials. Expert Rev Med Devices 2022; 19:977-989. [PMID: 36617696 DOI: 10.1080/17434440.2022.2165912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Discectomy and interbody fusion are widely used in the treatment of intervertebral disc-related diseases. Among them, the interbody cage plays a significant role. However, the complications related to the interbody cage, such as nonunion or pseudoarthrosis, subsidence, loosening, and prolapse of the cage, cannot be ignored. By changing the design and material of the interbody fusion cage, a better fusion effect can be obtained, the incidence of appeal complications can be reduced, and the quality of life of patients after interbody fusion can be improved. AREAS COVERED This study reviewed the research progress of cage design and material and discussed the methods of cage design and material to promote intervertebral fusion. EXPERT OPINION Current treatment of cervical and lumbar degenerative disease requires interbody fusion to maintain decompression and to promote fusion and reduce the incidence of fusion failure through improvements in implant material, design, internal structure, and function. However, interbody fusion is not an optimal solution for treating vertebral instability.Abbreviations: ACDF, Anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; Axi-aLIF, axial lumbar interbody fusion; BAK fusion cage, Bagby and Kuslich fusion cage; CADR, cervical artificial disc replacement; DBM, decalcified bone matrix; HA, hydroxyapatite; LLIF/XLIF, lateral or extreme lateral interbody fusion; MIS-TLIF, minimally invasive transforaminal lumbar interbody fusion; OLIF/ATP, oblique lumbar interbody fusion/anterior to psoas; PEEK, Poly-ether-ether-ketone; PLIF, posterior lumbar interbody fusion; ROI-C, Zero-profile Anchored Spacer; ROM, range of motion; SLM, selective melting forming; TLIF, transforaminal lumbar interbody fusion or.
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Affiliation(s)
- Guangshen Li
- Nantong University Medical School, 226000, Nantong, Jiangsu, China.,Department of Orthopedics, Hospital Affiliated 5 to Nantong University, Taizhou People's Hospital, 225300, Taizhou, China.,Department of Orthopedics, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Lei Yang
- Department of Orthopedics, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Gang Wu
- Department of Orthopedics, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Zhanyang Qian
- School of Medicine, Southeast University, Nanjing, China; Spine Center, Zhongda Hospital of Southeast University, Nanjing, China
| | - Haijun Li
- Nantong University Medical School, 226000, Nantong, Jiangsu, China.,Department of Orthopedics, Hospital Affiliated 5 to Nantong University, Taizhou People's Hospital, 225300, Taizhou, China.,Department of Orthopedics, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China.,Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, Jiangsu, China
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13
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Ramakrishna VAS, Chamoli U, Larosa AG, Mukhopadhyay SC, Prusty BG, Diwan AD. Finite element modeling of temporal bone graft changes in XLIF: Quantifying biomechanical effects at adjacent levels. J Orthop Res 2022; 40:1420-1435. [PMID: 34432322 DOI: 10.1002/jor.25166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/08/2021] [Accepted: 08/16/2021] [Indexed: 02/04/2023]
Abstract
Extreme lateral interbody fusion allows for the insertion of a large-footprint interbody cage while maintaining the presence of natural stabilizing ligaments and the facets. It is unclear how the load-distribution mechanisms through these structures alter with temporal changes in the bone graft. The aim of this study was to examine the effects of temporal bone graft changes on load distribution among the cage, graft, and surrounding spinal structures using finite element analysis. Thoracolumbosacral spine computed tomography data from an asymptomatic male subject were segmented into anatomical regions of interest and digitally stitched to generate a surface mesh of the lumbar spine (L1-S1). The interbody cage was inserted into the L4-L5 region during surface meshing. A volumetric mesh was generated and imported into finite element software for pre-processing, running nonlinear static solves, and post-processing. Temporal stiffening was simulated in the graft region with unbonded (Soft Callus, Temporal Stages 1-3, Solid Graft) and bonded (Partial Fusion, Full Fusion) contact. In flexion and extension, cage stress reduced by 20% from the soft callus to solid graft state. Force on the graft was directly related to its stiffness, and load-share between the cage and graft improved with increasing graft stiffness, regardless of whether contact was fused with the endplates. Fused contact between the cage-graft complex and the adjacent endplates shifted load-distribution pathways from the ligaments and facets to the implant, however, these changes did not extend to adjacent levels. These results suggest that once complete fusion is achieved, the existing load paths are seemingly diminished.
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Affiliation(s)
- Vivek A S Ramakrishna
- School of Mechanical and Manufacturing Engineering, Faculty of Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia.,Spine Labs, St. George & Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Uphar Chamoli
- Spine Labs, St. George & Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Alessandro G Larosa
- School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Subhas C Mukhopadhyay
- School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - B Gangadhara Prusty
- School of Mechanical and Manufacturing Engineering, Faculty of Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia
| | - Ashish D Diwan
- Spine Labs, St. George & Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Orthopaedic Surgery, Spine Service, St. George Hospital Campus, Kogarah, New South Wales, Australia
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14
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Toop N, Viljoen S, Baum J, Hatef J, Maggio D, Oosten J, Deistler K, Gilkey T, Close L, Farhadi HF, Grossbach AJ. Radiographic and clinical outcomes in one- and two-level transforaminal lumbar interbody fusions: a comparison of bullet versus banana cages. J Neurosurg Spine 2021:1-10. [PMID: 34920428 DOI: 10.3171/2021.8.spine21687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether cage morphology influences clinical and radiographic outcomes following short-segment transforaminal lumbar interbody fusion (TLIF) procedures. METHODS The authors retrospectively reviewed one- and two-level TLIFs at a single tertiary care center between August 2012 and November 2019 with a minimum 1-year radiographic and clinical follow-up. Two cohorts were compared based on interbody cage morphology: steerable "banana" cage or straight "bullet" cage. Patient-reported outcome measures (PROMs), radiographs, and complications were analyzed. RESULTS A total of 135 patients with 177 interbody levels were identified; 45 patients had 52 straight cages and 90 patients had 125 steerable cages. Segmental lordosis increased with steerable cages, while it decreased with straight cages (+3.8 ± 4.6 vs -1.9 ± 4.3, p < 0.001). Conversely, the mean segmental lordosis of adjacent lumbar levels decreased in the former group, while it increased in the latter group (-0.52 ± 1.9 vs +0.52 ± 2.1, p = 0.004). This reciprocal relationship results in global sagittal parameters, including pelvic incidence minus lumbar lordosis and lumbar distribution index, which did not change after surgery with either cage morphology. Multivariate analysis confirmed that steerable cage morphology, anterior cage positioning, and less preoperative index-level segmental lordosis were associated with greater improvement in index-level segmental lordosis. PROMs were improved after surgery with both cage types, and the degree of improvement did not differ between cohorts (p > 0.05). Perioperative and radiographic complications were similar between cohorts (p > 0.05). Overall reoperation rates, as well as reoperation rates for adjacent-segment disease within 2 years of surgery, were not significantly different between cohorts. CONCLUSIONS Steerable cages are more likely to lie within the anterior disc space, thus increasing index-level segmental lordosis, which is accompanied by a reciprocal change in segmental alignment at the adjacent lumbar levels. The converse relationship occurs for straight cages, with a kyphotic change at the index levels and reciprocal lordosis occurring at adjacent levels.
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Affiliation(s)
- Nathaniel Toop
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - Stephanus Viljoen
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - Justin Baum
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - Jeffrey Hatef
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - Dominic Maggio
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - James Oosten
- 2The Ohio State University School of Medicine, Columbus, Ohio
| | - Kyle Deistler
- 2The Ohio State University School of Medicine, Columbus, Ohio
| | - Ty Gilkey
- 2The Ohio State University School of Medicine, Columbus, Ohio
| | - Liesl Close
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - H Francis Farhadi
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
| | - Andrew J Grossbach
- 1Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
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15
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Mathew J, Cerpa M, Lee NJ, Boddapati V, Marciano G, Sardar ZM, Lenke LG. Comparing hyperlordotic and standard lordotic cages for achieving segmental lumbar lordosis during transforaminal lumbar interbody fusion in adult spinal deformity surgery. J Spine Surg 2021; 7:318-325. [PMID: 34734136 DOI: 10.21037/jss-21-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/02/2021] [Indexed: 11/06/2022]
Abstract
Background Few studies directly compare the effect of interbody cages with different degrees of lordosis in producing segmental lumbar lordosis (SLL) in the transforaminal lumbar interbody fusion (TLIF) procedure. Thus, we aimed to investigate changes in SLL in hyperlordotic cages compared to standard lordotic cages in open TLIF procedures. Methods Thirty-eight consecutive patients who received open TLIF procedures performed by a single surgeon between 2017 and 2018 were reviewed. Twenty patients had "hyperlordotic cages" (20° lordosis), while 18 patients had "standard lordotic cages" (6° lordosis). Twenty-three patients had one-level TLIF procedures and 15 had two-level TLIF. Standard radiographic measurements, including SLL were assessed preoperatively, postoperatively, and at 1-year follow-up. SLL was measured from the superior endplate of the cephalad vertebra to the inferior endplate of the caudal vertebra. Changes in SLL were compared using Student's and paired t-tests. Results In one- and two-level open TLIF, both hyperlordotic and standard lordotic cages produced significant improvement in SLL. Among those receiving a one-level TLIF, SLL increased 7.8° (P=0.024) in those with standard lordotic cages; it increased 8.2° (P=0.020) in those with hyperlordotic cages. Among those receiving a two-level TLIF, SLL increased 13.9° (P=0.032) in those with standard lordotic cages; it increased 8.8° (P=0.023) in those with hyperlordotic cages. However, the improvement in SLL was not significantly different between the two cage types in either one or two-level TLIF procedures (P=0.917, P=0.389). At 1-year follow-up, there was no significant change in SLL, among standard lordotic and hyperlordotic cages (P=0.501, P=0.781). Conclusions Although it is theorized that hyperlordotic cages would increase SLL during open TLIF procedures more than standard lordotic cages, our data failed to demonstrate that. As our study examined cases performed by a single surgeon immediately before and after adoption of these lordotic cages, it is likely that surgical technique is of equal or greater importance in improving SLL than the amount of lordosis designed into interbody cages.
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Affiliation(s)
- Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Gerard Marciano
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Zeeshan M Sardar
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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Ramey WL, Jack AS, Oskouian RJ, Hart RA, Chapman J. The Intradiscal Osteotomy: An Alternative Technique for Adult Spinal Deformity Correction. Cureus 2021; 13:e19062. [PMID: 34853767 PMCID: PMC8608666 DOI: 10.7759/cureus.19062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/09/2022] Open
Abstract
Adult spinal deformity (ASD) correction has changed considerably since the initial description of a Smith-Petersen osteotomy (SPO), including pedicle subtraction osteotomies (PSO), and more minimally invasive techniques. Here, we introduce and describe the intradiscal osteotomy (IDO), a novel variation of Schwab type 3 and 4 osteotomies allowing pedicle and vertebral body preservation, and its advantages and disadvantages. After pedicle screw placement, the posterior elements (except pedicles) are removed from the appropriate vertebrae, including the superior/inferior articulating processes, laminae, and spinous processes. An osteotome is used to remove the posterior aspect of the superior and inferior endplate, followed by the entire disc, creating more working room for eventual cage insertion. After the careful release of the annulus, an intradiscal distractor is used to distract the endplates and allow interbody cage insertion as anteriorly as possible. Pedicle and vertebral body preservation allow increased fixation and endplate cage support, which lengthens the anterior column and acts as a fulcrum when compressing posteriorly to restore lordosis. By allowing for anterior and posterior column release, the IDO technique provides a feasible, all-posterior approach for the correction of fixed or flexible kyphoscoliotic curves. This technical report introduces and describes the IDO as an alternative method for thoracic and/or lumbar ASD correction. More studies are required to fully elucidate its outcome vs. complication profile compared to other deformity correction techniques.
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Affiliation(s)
- Wyatt L Ramey
- Neurosurgery, Houston Methodist Neurological Institute, Houston, USA
| | | | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Robert A Hart
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Jens Chapman
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
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17
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Lovecchio FC, Vaishnav AS, Steinhaus ME, Othman YA, Gang CH, Iyer S, McAnany SJ, Albert TJ, Qureshi SA. Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion? Neurosurg Focus 2021; 49:E17. [PMID: 32871566 DOI: 10.3171/2020.6.focus20393] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology. METHODS The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted. RESULTS A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016). CONCLUSIONS Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Steven J McAnany
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Todd J Albert
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Sheeraz A Qureshi
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
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Erdoğan U. The Results of Using a Transforaminal Lumbar Interbody Fusion Cage at the Upper Lumbar Level. Cureus 2021; 13:e15496. [PMID: 34268027 PMCID: PMC8262652 DOI: 10.7759/cureus.15496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 12/04/2022] Open
Abstract
Aim The aim of this study is to apply surgical treatments to upper lumbar disc hernias in order to provide lumbar stability and lumbar lordosis using a transforaminal lumbar interbody fusion (TLIF) cage and to preserve the success rate of surgical results by protecting neural structures without excessive subject tension. Material and methods Between 2012 and 2017, 32 patients who had undergone an operation for upper lumbar disc herniation and who had received a transforaminal lumbar interbody fusion cage using a posterior technique were evaluated retrospectively. Results The radiological and clinical findings, surgical methods, and results of the patients were evaluated. In our study, 25 (78.1%) of the patients with upper lumbar disc hernias who were evaluated retrospectively were female and seven (21.9%) were male. Their average age was 55.43 years. The average follow-up was 21.75 months. The most common complaints were lower back pain, leg pain, and claudication. In the findings from neurological examinations, a positive result on the femoral stretching test occurred in 30 (93.7%) patients. In the degenerative spinal structure of patients at the L1-2 and L2-3 levels, a transforaminal lumbar interbody fusion was performed via a wide laminectomy with posterior stabilization due to a wide-bottomed disc hernia and stenosis. Only one of the patients with a neurological deficit still had a motor deficit after surgery. Conclusion While planning a surgery for upper lumbar disc hernias, the anatomical features of this region and the patients' radiological and neurological findings should be carefully evaluated. If TLIF is performed during upper lumbar region surgery, it may be preferable to perform it using a posterior technique.
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Affiliation(s)
- Uzay Erdoğan
- Neurosurgery, University of Health Sciences, Bakırköy Prof. Dr. Mazhar Osman Training and Research Hospital for Neurology, Neurosurgery and Psychiatry, Istanbul, TUR
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Li F, Zhan X, Xi X, Zeng Z, Ma B, Xie N, Zhu R, Tsai TY, Li G, Yu Y, Cheng L. Do the positioning variables of the cage contribute to adjacent facet joint degeneration? Radiological and clinical analysis following intervertebral fusion. Ann Transl Med 2021; 9:776. [PMID: 34268389 PMCID: PMC8246202 DOI: 10.21037/atm-20-7718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/05/2021] [Indexed: 12/28/2022]
Abstract
Background Compared to other risk factors, adjacent facet joint degeneration (AFD) is the main contributor to adjacent segment disease (ASD). The interbody cage may be a potential indirect risk of AFD. This study investigated the correlations among the lumbar sagittal balance parameters, the inter-body cage's intraoperative positioning variables, and adjacent facet joint degeneration following the transforaminal lumbar interbody fusion (TLIF) technique. Methods Patients who accepted single-level TLIF for symptomatic lumbar degenerative disease and were followed up for at least six months were enrolled in this study. According to the inclusive and exclusive criteria, 93 patients were included (44 males and 49 females). X-ray and computed tomography (CT) images were obtained before and six months after surgery. The vertebral contour and the center of the marker mass in the cage were calculated using a geometric algorithm. Orthopedic surgeons measured the disc height, lordosis angle, and facet joint degeneration. Patient-reported outcomes, including the Oswestry Disability Index (ODI) and the visual analog scale (VAS), were used to assess the clinical outcomes. The Student’s t-test, Wilcoxon rank-sum test, and Chi-square test were used for the statistical analyses. Results The average age was 53.7 years old (range, 27–84 years). The average functional disability outcome assessed by the ODI was 61.2, and the average back and leg pain assessed by the VAS was 6.2 and 6.9, respectively. The patients were categorized into a normal group and an abnormal (AFD) group according to whether the facet joint degeneration was aggravated. The abnormal group had a higher back pain VAS score (P=0.031) and lower sagittal vertical position (P=0.027). The other parameters were similar at baseline (P>0.05). The cage’s sagittal vertical position decreased significantly with AFD aggravation (OR, 0.737; 95% CI, 0.561–0.969). Conclusions In patients with AFD aggravation, the preoperative VAS and postoperative ODI scores were significantly higher. The cage position parameters were related to AFD. A lower cage center was associated with a greater incidence of AFD.
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Affiliation(s)
- Fuping Li
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Spine Surgery, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Xinhua Zhan
- Jiading Branch of Shanghai General Hospital, Shanghai, China.,Department of Orthopedics, Jiangqiao Hospital, Shanghai, China
| | - Xin Xi
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhili Zeng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bin Ma
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ning Xie
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhu
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Guoan Li
- Orthopedic Bioengineering Research Center, Department of Orthopedic Surgery, Newton-Wellesley, Hospital/Harvard Medical School, Wellesley, MA, USA
| | - Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liming Cheng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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20
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Butler JS, Lui DF, Malhotra K, Suarez-Huerta ML, Yu H, Selvadurai S, Agu O, Molloy S. 360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity. Global Spine J 2019; 9:613-618. [PMID: 31448194 PMCID: PMC6693065 DOI: 10.1177/2192568218814531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF). METHODS Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample t test and repeated-measures analysis of variance (rANOVA), was performed. RESULTS Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively (P < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years (P < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years (P < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years (P = .02). There were no neurological, vascular, or visceral approach-related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture. CONCLUSIONS The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.
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Affiliation(s)
- Joseph S. Butler
- Mater Misericordiae University Hospital, Dublin, Ireland,Tallaght University Hospital, Dublin, Ireland,Joseph S. Butler, National Spinal Injuries Unit,
Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital,
Eccles Street, Dublin 7, Ireland.
| | | | | | | | - Haiming Yu
- Royal National Orthopaedic Hospital, Stanmore, UK
| | | | | | - Sean Molloy
- Royal National Orthopaedic Hospital, Stanmore, UK
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21
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Sayari AJ, Patel DV, Yoo JS, Singh K. Device solutions for a challenging spine surgery: minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Expert Rev Med Devices 2019; 16:299-305. [PMID: 30917071 DOI: 10.1080/17434440.2019.1601013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Lumbar interbody fusion remains a mainstay in the treatment of degenerative spinal pathology. Interbody devices are often used in an attempt to improve fusion rates and outcomes. Minimally invasive techniques lend unique advantages, but are challenging and often plagued with complications. Specifically, minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has a steep learning curve and there is a lack of concise information on solutions to optimize outcomes. AREAS COVERED This review details an appropriate surgical technique of MIS TLIF and includes an overview of the components that go into a successful procedure. A thorough literature search of the PubMed database was completed to provide a comprehensive analysis of the interbody devices, posterolateral fixation, and osteobiologics. EXPERT OPINION MIS TLIFs have demonstrated successful clinical and radiographic outcomes and have become a mainstay for treating various degenerative lumbar pathologies. As minimally invasive techniques continue to evolve, devices and biologics will continue to expand the indications for MIS TLIFs and will optimize long-term outcomes.
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Affiliation(s)
- Arash J Sayari
- a Department of Orthopaedic Surgery , Rush University Medical Center , Chicago , IL , USA
| | - Dil V Patel
- a Department of Orthopaedic Surgery , Rush University Medical Center , Chicago , IL , USA
| | - Joon S Yoo
- a Department of Orthopaedic Surgery , Rush University Medical Center , Chicago , IL , USA
| | - Kern Singh
- a Department of Orthopaedic Surgery , Rush University Medical Center , Chicago , IL , USA
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22
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Kersten RFMR, Wu G, Pouran B, van der Veen AJ, Weinans HH, de Gast A, Öner FC, van Gaalen SM. Comparison of polyetheretherketone versus silicon nitride intervertebral spinal spacers in a caprine model. J Biomed Mater Res B Appl Biomater 2018; 107:688-699. [PMID: 30091515 DOI: 10.1002/jbm.b.34162] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 04/22/2018] [Accepted: 04/29/2018] [Indexed: 12/17/2022]
Abstract
Polyetheretherketone (PEEK) is commonly used as a spinal spacer for intervertebral fusion surgery. Unfortunately, PEEK is bioinert and does not effectively osseointegrate into living bone. In contrast, comparable spacers made of silicon nitride (Si3 N4 ) possess a surface nanostructure and chemistry that encourage appositional bone healing. This observational study was designed to compare the outcomes of these two biomaterials when implanted as spacers in an adult caprine model. Lumbar interbody fusion surgeries were performed at two adjacent levels in eight adult goats using implants of PEEK and Si3 N4 . At six-months after surgery, the operative and adjacent spinal segments were extracted and measured for bone fusion, bone volume, bone-implant contact (BIC) and soft-tissue implant contact (SIC) ratios, and biodynamic stability. The null hypothesis was that no differences in these parameters would be apparent between the two groups. Fusion was observed in seven of eight implants in each group with greater bone formation in the Si3 N4 group (52.6%) versus PEEK (27.9%; p = 0.2). There were no significant differences in BIC ratios between PEEK and Si3 N4 , and the biodynamic stability of the two groups was also comparable. The results suggest that Si3 N4 spacers are not inferior to PEEK and they may be more effective in promoting arthrodesis. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000-000, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 688-699, 2019.
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Affiliation(s)
- Roel F M R Kersten
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands.,Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gang Wu
- Department of Oral Implantology and Prosthetic Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit (VU), Amsterdam, The Netherlands
| | - Behdad Pouran
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Albert J van der Veen
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harrie H Weinans
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Arthur de Gast
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands
| | - F Cumhur Öner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven M van Gaalen
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands
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Abstract
Lumbar fusion surgery is an established procedure for the treatment of low back pain. Despite the wide set of alternative fusion techniques and existing devices, uniform guidelines are not available yet and common surgical trends are scarcely investigated.The purpose of this UK-based study was to provide a descriptive portrait of current surgeons' practice and implant preferences in lumbar fusion surgery.A UK-based in-person survey was designed for this study and submitted to a group of consultant spinal surgeons (n = 32). Fifteeen queries were addressed based on different aspects of surgeons' practice: lumbar fusion techniques, implant preferences, and bone grafting procedures. Answers were analyzed by means of descriptive statistics.Thirty-two consultant spinal surgeons completed the survey. There was clear consistency on the relevance of a patient-centered management (82.3%), along with a considerable variability of practice on the preferred fusion approach. Fixation surgery was found to be largely adopted (96.0%) and favored over stand-alone cages. With regards to the materials, titanium cages were the most used (54.3%). The geometry of the implants influenced the choice of lumbar cages (81.3%). Specifically, parallel-shape cages were mostly avoided (89.2%) and hyperlordotic cages were preferred at the lower lumbar levels. However, there was no design for lumbar cages which was consistently favored. Autograft bone graft surgeries were the most common (60.0%). Amongst the synthetic options, hydroxyapatite-based bone graft substitutes (76.7%) in injectable paste form (80.8%) were preferred.Current lumbar fusion practice is variable and patient-oriented. Findings from this study highlight the need for large-scale investigative surveys and clinical studies aimed to set specific guidelines for certain pathologies or patient categories.
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Affiliation(s)
- Elena Provaggi
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science
| | - Claudio Capelli
- Institute of Cardiovascular Science, Great Ormond Street Hospital for Children, University College London (UCL), London, United Kingdom
| | - Julian J.H. Leong
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Royal National Orthopedic Hospital, Brockley Hill, Stanmore, Middlesex, United Kingdom
| | - Deepak M. Kalaskar
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science
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24
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Zhang Z, Fogel GR, Liao Z, Sun Y, Liu W. Biomechanical analysis of lumbar interbody fusion cages with various lordotic angles: a finite element study. Comput Methods Biomech Biomed Engin 2018. [PMID: 29513028 DOI: 10.1080/10255842.2018.1442443] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Inappropriate lordotic angle of lumbar fusion cage could be associated with cage damage or subsidence. The biomechanical influence of cage lordotic angle on lumbar spine has not been fully investigated. Four surgical finite element models were constructed by inserting cages with various lordotic angles at L3-L4 disc space. The four motion modes were simulated. The range of motion (ROM) decreased with increased lordotic angle of cage in flexion, extension, and rotation, whereas it was not substantially changed in bending. The maximum stress in cage decreased with increased lordotic angle of cage in all motion modes. The maximum stress in endplate at surgical level increased with increased lordotic angle of cage in flexion and rotation, whereas it was not substantially changed in extension and bending. The facet joint force (FJF) was much smaller than that for the intact conditions in extension, bending, and rotation, while it was not substantially changed in flexion. In conclusion, the ROM, stresses in the cage and endplate at surgical level are sensitive to the lordotic angle of cage. The increased cage lordotic angle may provide better stability and reduce the risk of cage damage, whereas it may increase the risk of subsidence in flexion and rotation.
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Affiliation(s)
- Zhenjun Zhang
- a Department of Mechanical Engineering , Tsinghua University , Beijing , China.,b Biomechanics and Biotechnology Lab , Research Institute of Tsinghua University in Shenzhen , Shenzhen , China
| | - Guy R Fogel
- c Spine Pain Begone Clinic , San Antonio , TX , USA
| | - Zhenhua Liao
- b Biomechanics and Biotechnology Lab , Research Institute of Tsinghua University in Shenzhen , Shenzhen , China
| | - Yitao Sun
- d Haicheng City Central Hospital , Haicheng , China
| | - Weiqiang Liu
- a Department of Mechanical Engineering , Tsinghua University , Beijing , China.,b Biomechanics and Biotechnology Lab , Research Institute of Tsinghua University in Shenzhen , Shenzhen , China
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25
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Abstract
Study Design This study was a retrospective observational study. Purpose The purpose of the study was to determine the radiological and clinical outcome of using locally sourced autologous bone graft in the surgical management of single-level lumbar lytic spondylolisthesis. Background Many spinal surgeons supplement pedicle screw fixation of lumbar spondylolisthesis with cages. In developing countries, the high cost of interbody cages has precluded their use, with surgeons resorting to filling the interbody space with different types of bone graft instead. This study reports on the clinical and radiological outcome of posterior lumbar interbody fusions for low-grade lytic spondylolisthesis using locally sourced autologous bone graft. Material and Methods Posterior interbody fusion was performed in 22 consecutive patients over 18-month period, using (BRAND) pedicle screw system and locally sourced bone graft, i.e., bone removed during neural decompression. There were no postoperative restrictions, and all patients underwent clinical outcome measurements using Oswestry Disability Index (ODI), visual analogue pain score (VAS) at a minimum follow-up of 12 months, and computed tomography (CT) assessment of fusion with intraobserver validation by radiology consultant blinded, at 6 and12 months. Nearly 50% of the population were smokers. Results There was significant clinical improvement in ODI, VAS back pain, and VAS leg pain (P < 0.001). By contrast, the radiologic fusion rate measured by CT at 12 months was less satisfactory at 64%. There was no difference in clinical outcome between the fused group and nonfused population. Conclusions These results indicate that the use of locally sourced bone graft in single-level lumbar lytic low-grade spondylolisthesis. Interbody fusion provides good clinical outcomes. The use of an interbody cage may not be clinically necessary. Our radiologic outcome, however, shows inferior fusion rates compared with published data. Future research will focus on long-term outcomes.
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Affiliation(s)
- Joseph Boktor
- Department of Orthopedic, Kasr Al Ainy Medical School, Cairo University, Egypt.,Department of Spine Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Tishi Ninan
- Department of Spine Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, College of human and Health Sciences, Swansea University, Swansea, UK
| | - Iona Collins
- Department of Spine Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Ahmed Sultan
- Department of Orthopedic, Kasr Al Ainy Medical School, Cairo University, Egypt
| | - Wael Koptan
- Department of Orthopedic, Kasr Al Ainy Medical School, Cairo University, Egypt
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26
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Comer GC, Behn A, Ravi S, Cheng I. A Biomechanical Comparison of Shape Design and Positioning of Transforaminal Lumbar Interbody Fusion Cages. Global Spine J 2016; 6:432-8. [PMID: 27433426 PMCID: PMC4947403 DOI: 10.1055/s-0035-1564568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 08/12/2015] [Indexed: 10/24/2022] Open
Abstract
STUDY DESIGN Cadaveric biomechanical analysis. OBJECTIVE The aim of this study was to compare three interbody cage shapes and their position within the interbody space with regards to construct stability for transforaminal lumbar interbody fusion. METHODS Twenty L2-L3 and L4-L5 lumbar motion segments from fresh cadavers were potted in polymethyl methacrylate and subjected to testing with a materials testing machine before and after unilateral facetectomy, diskectomy, and interbody cage insertion. The three cage types were kidney-shaped, articulated, and straight bullet-shaped. Each cage type was placed in a common anatomic area within the interbody space before testing: kidney, center; kidney, anterior; articulated, center; articulated, anterior; bullet, center; bullet, lateral. Load-deformation curves were generated for axial compression, flexion, extension, right bending, left bending, right torsion, and left torsion. Finally, load to failure was tested. RESULTS For all applied loads, there was a statistically significant decrease in the slope of the load-displacement curves for instrumented specimens compared with the intact state (p < 0.05) with the exception of right axial torsion (p = 0.062). Among all instrumented groups, there was no statistically significant difference in stiffness for any of the loading conditions or load to failure. CONCLUSIONS Our results failed to show a clearly superior cage shape design or location within the interbody space for use in transforaminal lumbar interbody fusion.
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Affiliation(s)
- Garet C. Comer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States
| | - Anthony Behn
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States
| | - Shashank Ravi
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States,Address for correspondence Ivan Cheng, MD Department of Orthopaedic Surgery, Stanford University450 Broadway Street, Redwood City, CA 94063United States
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27
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Freeman AL, Camisa WJ, Buttermann GR, Malcolm JR. Flexibility and fatigue evaluation of oblique as compared with anterior lumbar interbody cages with integrated endplate fixation. J Neurosurg Spine 2015; 24:54-9. [PMID: 26407089 DOI: 10.3171/2015.4.spine14948] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was undertaken to quantify the in vitro range of motion (ROM) of oblique as compared with anterior lumbar interbody devices, pullout resistance, and subsidence in fatigue. METHODS Anterior and oblique cages with integrated plate fixation (IPF) were tested using lumbar motion segments. Flexibility tests were conducted on the intact segments, cage, cage + IPF, and cage + IPF + pedicle screws (6 anterior, 7 oblique). Pullout tests were then performed on the cage + IPF. Fatigue testing was conducted on the cage + IPF specimens for 30,000 cycles. RESULTS No ROM differences were observed in any test group between anterior and oblique cage constructs. The greatest reduction in ROM was with supplemental pedicle screw fixation. Peak pullout forces were 637 ± 192 N and 651 ± 127 N for the anterior and oblique implants, respectively. The median cage subsidence was 0.8 mm and 1.4 mm for the anterior and oblique cages, respectively. CONCLUSIONS Anterior and oblique cages similarly reduced ROM in flexibility testing, and the integrated fixation prevented device displacement. Subsidence was minimal during fatigue testing, most of which occurred in the first 2500 cycles.
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Affiliation(s)
- Andrew L Freeman
- Excelen Center for Bone and Joint Research, Minneapolis, Minnesota
| | - William J Camisa
- Excelen Center for Bone and Joint Research, Minneapolis, Minnesota
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28
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Wang SJ, Han YC, Pan FM, Ma B, Tan J. Single transverse-orientation cage via MIS-TLIF approach for the treatment of degenerative lumbar disease: a technical note. Int J Clin Exp Med 2015; 8:14154-14160. [PMID: 26550387 PMCID: PMC4613072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/23/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Single transverse cage placed in the anterior vertebral column can better maintain lumbar lordosis and sagittal alignment and is frequently used via the lateral transpsoas approach. However, there is no clear description in the literature of the steps required to place the single transverse cage during the instrumented transforaminal lumbar interbody fusion (TLIF) procedure for the treatment of degenerative lumbar disease. The objective of this study is to describe the technique using single transverse-orientation cage when performing TLIF procedures. MATERIALS AND METHODS We present 18 illustrative cases in which single transverse-orientation cage was placed according to a step-by-step technique that can be used during the TLIF procedure. Information acquired included procedure time, intraoperative blood loss and postoperative complications. The preoperative and postoperative Oswestry Disability Index (ODI) and the visual analogue scale (VAS) scores were recorded. Changes in disc height and segmental lordosis were measured at radiographs. RESULTS The single transverse-orientation cage was successfully placed in 18 patients in a stepwise technique to achieve lumbar fusion. Using this technique, the patients significantly improved clinically and radiographically at postoperative visits. CONCLUSIONS This is the first report demonstrating the safety and efficacy of instrumented TLIF with single transverse-orientation cage for the treatment of degenerative lumbar disease. Single transverse-orientation cage via MIS-TLIF approach can maintain greater lumbar lordosis and avoid the unique complications of lateral transpsoas approach. Understanding the options for cage placement is important for surgeons considering the use of this technique.
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Affiliation(s)
- Shan-Jin Wang
- Departments of Spinal Surgery, Shanghai East Hospital, Tongji University School of MedicineShanghai, China
| | - Ying-Chao Han
- Departments of Spinal Surgery, Shanghai East Hospital, Tongji University School of MedicineShanghai, China
| | - Fu-Min Pan
- Departments of Spinal Surgery, Shanghai East Hospital, Tongji University School of MedicineShanghai, China
| | - Bin Ma
- Departments of Spinal Surgery, Shanghai East Hospital, Tongji University School of MedicineShanghai, China
| | - Jun Tan
- Departments of Spinal Surgery, Shanghai East Hospital, Tongji University School of MedicineShanghai, China
- Department of Orthopedics, Pinghu Second People’s HospitalJiaxing, China
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29
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Abstract
Objective: To analyze the clinical and radiographic results following the use of integrated intervertebral implant in patients with cervical spine degenerative disease. Background: Though excellent results have been reported following anterior cervical discectomy and fusion using iliac crest autograft/allograft with plating, the morbidity associated with autograft harvest and small chances of complications with plating always exists. Recently, there has been development of a cervical stand-alone cage with integrated fixation for cervical fusion and stabilization with a possible low morbidity and optimal clinical outcome. Materials and Methods: A retrospective study of 16 patients who underwent anterior cervical discectomy and fusion using the integrated intervertebral device was performed. Intra-operative parameters, clinical features [Neck Disability Index (NDI), visual analog scale (VAS) score for neck/arm pain], and presence or absence of dysphagia was recorded. Radiographs were evaluated for assessment of implant failure and fusion. Results: Mean age of patients was 54 years (range: 38-84 years) with male: female ratio of 1:3. Follow-up ranged from 6 to 12 months (mean: 10 months). In the early postoperative period, 2 of the 15 patients (13%) patients had mild dysphagia that resolved during follow-up with no patient having complaints of dysphagia at 3-month follow-up. One of the patients with diffuse idiopathic skeletal hyperostosis (DISH) and severe preoperative dysphagia had significant improvement in swallowing function at 3-month follow-up that was stable at 1-year follow-up. There was no evidence of implant failure, with fusion occurring in 95% (19/20) of operated levels. Analysis of follow-up VAS and NDI scores showed significant reduction in VAS score for neck pain (P < 0.019), radicular arm pain (P < 0.003), and NDI score (P < 0.007) in 77, 92, and 77% of patients, respectively, at a mean follow-up of 10 months (6-12 months). Conclusions: Our preliminary results with the use of this cervical stand-alone anterior fusion device with integrated screw fixation show its efficacy in anterior cervical decompression and fusion with stabilization with optimal clinical and radiographic outcome. Lower chances of dysphagia with no device-related complications are appealing, which needs to be verified in larger studies.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, RUSH University Medical Center, Chicago, Illinois, USA
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