Changes in Segmental and Lumbar Lordosis After Lateral Lumbar Interbody Fusion With Different Lordotic Cage Angulations

Bakare, Adewale A.; Fessler, David R.; Wewel, Joshua T.; Fontes, Ricardo B. V.; Fessler, Richard G.; O’Toole, John E.

doi:10.14444/8066

Cited by 8 publications

(8 citation statements)

References 31 publications

(44 reference statements)

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“…They reported a change in LL for P-LLIF (9.9°) that is higher than previously reported values of 3.7 to 6.3° 19,21 . This is coupled with the fact that they found a change in LL of 0.5 amongst the L-LLIF group which is smaller than established in prior literature, which ranges from 2 to 7.5°, with a large metanalysis showing a mean 4.5° increase in LL 9,24–26 …”

Section: Discussionmentioning

confidence: 55%

Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion

Buckland

Proctor

Thomas³

et al. 2023

Spine

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Study Design. Multi-centre retrospective cohort study. Objective. To evaluate the feasibility and safety of the singleposition prone lateral lumbar interbody fusion (LLIF) technique for revision lumbar fusion surgery. Background Context. Prone LLIF (P-LLIF) is a novel technique allowing for placement of a lateral interbody in the prone position and allowing posterior decompression and revision of posterior instrumentation without patient repositioning. This study examines perioperative outcomes and complications of single position P-LLIF against traditional Lateral LLIF (L-LLIF) technique with patient repositioning. Method. A multi-centre retrospective cohort study involving patients undergoing 1 to 4 level LLIF surgery was performed at 4 institutions in the US and Australia. Patients were included if their surgery was performed via either: P-LLIF with revision posterior fusion; or L-LLIF with repositioning to prone. Demographics, perioperative outcomes, complications, and radiological outcomes were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at P < 0.05. Results. 101 patients undergoing revision LLIF surgery were included, of which 43 had P-LLIF and 58 had L-LLIF. Age, BMI and CCI were similar between groups. The number of posterior levels fused (2.21 P-LLIF vs. 2.66 L-LLIF, P = 0.469) and number of LLIF levels (1.35 vs. 1.39, P = 0.668) was similar between groups. Operative time was significantly less in the P-LLIF group (151 vs. 206 min, P = 0.004). EBL was similar between groups (150mL P-LLIF vs. 182mL L-LLIF, P = 0.31) and there was a trend toward reduced length of stay in the P-LLIF group (2.7 vs. 3.3d, P = 0.09). No significant difference was demonstrated in complications between groups. Radiographic analysis demonstrated no significant differences in preoperative or postoperative sagittal alignment measurements. Conclusion. P-LLIF significantly improves operative efficiency when compared to L-LLIF for revision lumbar fusion. No increase in complications was demonstrated by P-LLIF or trade-offs in sagittal alignment restoration.

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Section: Discussionmentioning

confidence: 55%

Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion

Buckland

Proctor

Thomas³

et al. 2023

Spine

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“…2 However, in our study, only 7.5% of fused levels became kyphotic, consistent with the literature on the reliability of LLIFs. 1,4,16,20,21 Moreover, cages placed more anteriorly provided greater improvements in overall lordosis, segmental lordosis, and anterior disc height, while those placed more posteriorly provided greater posterior disc space restoration, which may indicate better indirect decompression. These findings demonstrate that patient-specific factors will likely determine the ideal cage placement.…”

Section: Discussionmentioning

confidence: 98%

“…Cage geometry, including lordotic angle and implant size, and cage placement have both been suggested to play integral roles in radiographic outcomes. 7,[12][13][14][15][16] However, recent studies have not demonstrated an association between degree of cage lordosis and correction of sagittal parameters following interbody fusion. 13,14,17 The role of cage geometry and placement during LLIF procedures continues to remain unclear.…”

Section: Issa Et Almentioning

confidence: 99%

The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion

Issa

Lee

Lambrechts

et al. 2023

Neurosurgical Focus

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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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“…In addition, the type of interbody device was at the discretion of the surgeon, and the use of allograft or an interbody cage may have increased heterogeneity within the findings due to differences in SL improvement. 36 We measured intervertebral disc height at the first postoperative imaging, so any subsidence that occurred between the operative radiograph and first follow up was not recorded. Finally, the differences in radiographic parameters were typically <10°, thus their clinical relevance may be limited.…”

Section: Discussionmentioning

confidence: 99%

“…Patients without complete preoperative, intraoperative, and postoperative imaging were excluded which may have imparted a follow-up bias. In addition, the type of interbody device was at the discretion of the surgeon, and the use of allograft or an interbody cage may have increased heterogeneity within the findings due to differences in SL improvement 36. We measured intervertebral disc height at the first postoperative imaging, so any subsidence that occurred between the operative radiograph and first follow up was not recorded.…”

Section: Discussionmentioning

confidence: 99%

A Short-Term Assessment of Lumbar Sagittal Alignment Parameters in Patients Undergoing Anterior Lumbar Interbody Fusion

Lambrechts

Siegel

Karamian

et al. 2022

Spine

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Study Design. Retrospective cohort. Objective. To determine if intraoperative on-table lumbar lordosis (LL) and segmental lordosis (SL) coincide with perioperative change in lordosis. Summary of Background Data. Improvements in sagittal alignment are believed to correlate with improvements in clinical outcomes. Thus, it is important to establish whether intraoperative radiographs predict postoperative improvements in LL or SL. Materials and Methods. Electronic medical records were reviewed for patients ≥18 years old who underwent single-level and two-level anterior lumbar interbody fusion with posterior instrumentation between 2016 and 2020. LL, SL, and the lordosis distribution index were compared between preoperative, intraoperative, and postoperative radiographs using paired t tests. A linear regression determined the effect of subsidence on SL and LL. Results. A total of 118 patients met inclusion criteria. Of those, 75 patients had one-level fusions and 43 had a two-level fusion. LL significantly increased following on-table positioning [delta (Δ): 5.7°, P<0.001]. However, LL significantly decreased between the intraoperative to postoperative radiographs at two to six weeks (Δ: −3.4°, P=0.001), while no change was identified between the intraoperative and more than three-month postoperative radiographs (Δ: −1.6°, P=0.143). SL was found to significantly increase from the preoperative to intraoperative radiographs (Δ: 10.9°, P<0.001), but it subsequently decreased at the two to six weeks follow up (Δ: −2.7, P<0.001) and at the final follow up (Δ: −4.1, P<0.001). On linear regression, cage subsidence/allograft resorption was predictive of the Δ SL (β=0.55; 95% confidence interval: 0.16–0.94; P=0.006), but not LL (β=0.10; 95% confidence interval: −0.44 to 0.65; P=0.708). Conclusion. Early postoperative radiographs may not accurately reflect the improvement in LL seen on intraoperative radiographic imaging, but they are predictive of long-term lumbar sagittal alignment. Each millimeter of cage subsidence or allograft resorption reduces SL by 0.55°, but subsidence does not significantly affect LL. Levels of Evidence: 4

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Changes in Segmental and Lumbar Lordosis After Lateral Lumbar Interbody Fusion With Different Lordotic Cage Angulations

Cited by 8 publications

References 31 publications

Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion

Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion

The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion

A Short-Term Assessment of Lumbar Sagittal Alignment Parameters in Patients Undergoing Anterior Lumbar Interbody Fusion

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