Expandable vs Static Cages in Transforaminal Lumbar Interbody Fusion: Radiographic Comparison of Segmental and Lumbar Sagittal Angles

Yee, Timothy J; Joseph, Jacob R.; Terman, Samuel W.; Park, Paul

doi:10.1093/neuros/nyw177

Cited by 44 publications

(35 citation statements)

References 28 publications

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“…However, a study by Yee et al yielded less encouraging results [75]. They performed a retrospective cohort study of patients undergoing single-level TLIF with either an expandable cage or a static cage to determine which type of cage was better able to improve lumbar lordosis.…”

Section: Resultsmentioning

confidence: 99%

Interbody Fusions in the Lumbar Spine: A Review

2020

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Background Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height. Questions/Purposes We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine. Methods Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review. Results Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK–titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation. Conclusions All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.

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Section: Resultsmentioning

confidence: 99%

Interbody Fusions in the Lumbar Spine: A Review

2020

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“…By way of historical comparison with traditional MIS TLIF, other studies have demonstrated 2°-3° of segmental correction in the sagittal plane. 15,21,23,48 In comparison with other forms of sagittal correction, historically MIS TLIF has shown only modest improvements in segmental lordotic angle. Additionally, the increase in segmental lordotic restoration in this study compares favorably to a weighted average increase of 3.9° published in a review by Uribe et al 43 Despite these positive findings, it is important to note that the question whether improvement in LL translates into actual improved clinical outcomes for treatment of spondylolisthesis has not been reliably answered in the literature.…”

Section: Key Resultsmentioning

confidence: 99%

Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis

Massie¹,

Zakaria²,

Schultz

et al. 2018

Neurosurgical Focus

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OBJECTIVEThe inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF.METHODSThis is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain.RESULTSThirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = −0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = −0.425, p = 0.043, and r = −0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = −0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = −0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate.Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT.CONCLUSIONSThe use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.

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“…Therefore, the authors concluded that an expandable device alone do not consistently achieve greater increases in lumbar and SL. [ 18 ] Studies evaluating the effect of expandable cages on lordosis in TLIF are rare. A cadaveric study was published by Qandah et al .…”

Section: Discussionmentioning

confidence: 99%

“…Our data show better results than in comparable literature. [ 17 18 ] Ahlquist et al . compared different approaches and found that ALIF and LLIF produced greater improvement in radiographic measurements in comparison to TLIF and PLIF.…”

Section: Discussionmentioning

confidence: 99%

Transforaminal lumbar interbody fusion with expandable cages: Radiological and clinical results of banana-shaped and straight implants

Tassemeier

Haversath

Jäger

2018

J Craniovert Jun Spine

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Purpose:Expandable titanium transforaminal lumbar interbody fusion (TLIF) devices are a relatively new group of implants allowing restoration of lumbar lordosis (LL) and thus improvement of sagittal alignment. The purpose of our study is to compare clinical and radiological results of two different expandable TLIF devices.Materials and Methods:In a retrospective study, patients who underwent TLIF surgery with a banana-shaped or straight TLIF cage in our spine center were analyzed. Primary outcome was change of disc height (DH), segmental lordosis angle (SLA), and lumbar lordotic angle (LLA). Moreover, basic patients parameters and cage subsidence were evaluated.Results:Sixty-one patients were studied (33 banana-shaped and 28 straight cages). DH changed in the banana group from 4.8 mm (standard deviation SD 2.5) to 10.4 (SD 2.4) and in the straight cage group from 6.2 mm (SD 2.5) to 9.6 mm (SD 1.7). The difference was statistically significant (P = 0.03). In addition, SLA correction was higher in the banana group with 5.8° (SD 5.0)–3.7° (SD 3.6), but not significant. LLA improved in the straight group with 5.2 (SD 6.4) compared to 3.7° (SD 5.8) in the banana group. We found subsidence in four patients (6.6%) in the banana-shaped group and nine cases (14.8%) in the other group.Conclusions:Expandable titanium implants show similar improvements in restoring segmental and global lordosis. Banana-shaped expandable cages offer higher potency restoring the intervertebral DH and show less rates of subsidence compared to straight expandable cages.

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Expandable vs Static Cages in Transforaminal Lumbar Interbody Fusion: Radiographic Comparison of Segmental and Lumbar Sagittal Angles

Abstract: Patients undergoing single-level TLIF experienced similar improvements in SL and LL regardless of whether nonexpandable or expandable cages were placed.

Cited by 44 publications

References 28 publications

Interbody Fusions in the Lumbar Spine: A Review

Interbody Fusions in the Lumbar Spine: A Review

Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis

Transforaminal lumbar interbody fusion with expandable cages: Radiological and clinical results of banana-shaped and straight implants

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