Interbody Fusions in the Lumbar Spine: A Review

Abstract

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

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

“…lumbar interbody fusion (OLIF) technique has been developed and used to compensate for the shortcomings of the LIF technique. In the case of OLIF surgery, direct correction can be performed on the anterior column of the spine while preserving the psoas muscle, thus protecting the anterior and posterior muscles of the vertebral body [59].…”

Transforaminal Lumbar Interbody Fusion (TLIF) versus Oblique Lumbar Interbody Fusion (OLIF) in Interbody Fusion Technique for Degenerative Spondylolisthesis: A Systematic Review and Meta-Analysis

“…Lateral-access cage insertion techniques via the retroperitoneal space have been invented to reduce the problems related to TLIF procedures, including lateral lumbar interbody fusion (LLIF) or oblique lateral interbody fusion (OLIF) [ 2 , 4 , 7 , 11 , 12 , 13 , 14 , 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. LLIF is conducted via the intermuscular approach dissecting the psoas muscle; thus, it can cause psoas muscle-related complications, including anterior thigh pain, leg weakness, nerve root injury, and others [ 2 , 4 , 11 , 13 , 14 , 25 , 29 ]. To overcome the problems of LLIF, the OLIF procedure has been recently developed.…”

“…The OLIF procedure is conducted in the space between the abdominal aorta and psoas muscle, so the risk of psoas muscle injury could be reduced. In addition, several studies have demonstrated that the OLIF procedure provides better outcomes and lower complications than the LLIF procedure [ 2 , 4 , 5 , 11 , 14 , 27 , 29 , 30 , 32 , 34 ].…”

The Feasibility of 3D Intraoperative Navigation in Lateral Lumbar Interbody Fusion: Perioperative Outcomes, Accuracy of Cage Placement and Radiation Exposure

“…10,11 Furthermore, the ability to place a large interbody cage to restore disc height and achieve indirect central and foraminal decompression without direct visualization of the neural elements spares the morbidity and complication profile of the posterior approach. [12][13][14][15][16][17][18] However, due to the possibility of approach-related complications including lumbosacral plexus injury, intraoperative radiographic guidance and neuromonitoring are of paramount importance. [19][20][21] Although fluoroscopy has been the mainstay for intraoperative radiographic guidance during LLIF procedures, 3D intraoperative navigation (ION) is being increasingly considered as it may provide for potentially increased accuracy of interbody placement and decreased radiation exposure to operating room staff.…”