Reasons for revision following stand-alone anterior lumbar interbody fusion and lateral lumbar interbody fusion

Abstract

OBJECTIVE Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are alternative and less invasive techniques to stabilize the spine and indirectly decompress the neural elements compared with open posterior approaches. While reoperation rates have been described for open posterior lumbar surgery, there are sparse data on reoperation rates following these less invasive procedures without direct posterior decompression. This study aimed to evaluate the overall rate, cause, and timing of reoperation procedures following anterior or lateral lumbar interbody fusions without direct posterior decompression. METHODS This was a retrospective cohort study of all consecutive patients indicated for an ALIF or LLIF for lumbar spine at a single academic institution. Patients who underwent concomitant posterior fusion or direct decompression surgeries were excluded. Rates, causes, and timing of reoperations were analyzed. Patients who underwent a revision decompression were matched with patients who did not require a reoperation, and preoperative imaging characteristics were analyzed to assess for risk factors for the reoperation. RESULTS The study cohort consisted of 529 patients with an average follow-up of 2.37 years; 40.3% (213/529) and 67.3% (356/529) of patients had a minimum of 2 years and 1 year of follow-up, respectively. The total revision rate was 5.7% (30/529), with same-level revision in 3.8% (20/529) and adjacent-level revision in 1.9% (10/529) of patients. Same-level revision patients had significantly shorter time to revision (7.14 months) than adjacent-level revision patients (31.91 months) (p < 0.0001). Fifty percent of same-level revisions were for a posterior decompression. After further analysis of decompression revisions, an increased preoperative canal area was significantly associated with a lower risk of further decompression revision compared to the control group (p = 0.015; OR 0.977, 95% CI 0.959–0.995). CONCLUSIONS There was a low reoperation rate after anterior or lateral lumbar interbody fusions without direct posterior decompression. The majority of same-level reoperations were due to a need for further decompression. Smaller preoperative canal diameters were associated with the need for revision decompression.

Outcomes Following Direct Versus Indirect Decompression Techniques for Lumbar Spondylolisthesis

“…Univariate analysis showed significantly higher rates of revision surgery within the first 3 months for the ID group in this study. The higher rate of revision surgery could be due to a greater frequency of inadequate decompression, which has been cited as the main cause of same-level revisions for ID 28. In addition, the ID group reported significantly lower rates of patient satisfaction at 3 and 12 months, however, these were not significantly different in the multivariable analysis, suggesting that covariates, such as demographic factors or psychological distress, may confound patient expectations.…”

Is Standalone Lateral Lumbar Interbody Fusion Enough?

“…This highlights the need for patient and pathology specific treatment strategies, as the majority of revisions performed in the LLIF cohorts were done so for persistent bony lateral recess stenosis rather than recurrent stenosis. 13 In addition, as standalone procedures have the benefit of not violating any of the significant stabilizing soft tissues of all 3 spinal columns, they have the theoretical benefit of minimizing iatrogenic instability and need for future reoperation secondary to adjacent segment disease (ASD). In fact, in a study by Nayar et al, 14 the risk for ASD following standalone LLIF was only 3.3% over 4 years, with an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI: 0.67%-1.09%) per year.…”

“…Another recent investigation of 529 cases comparing standalone interbody fusion (anterior lumbar interbody fusion or LLIF) versus those with adjunct percutaneous fixation found no difference in revision rates between the cohorts, with an overall same-level revision surgery rate of 3.8%, of which only 3 (all in the anterior lumbar interbody fusion cohort) were secondary to recurrent stenosis attributed to cage subsidence. This highlights the need for patient and pathology specific treatment strategies, as the majority of revisions performed in the LLIF cohorts were done so for persistent bony lateral recess stenosis rather than recurrent stenosis 13 . In addition, as standalone procedures have the benefit of not violating any of the significant stabilizing soft tissues of all 3 spinal columns, they have the theoretical benefit of minimizing iatrogenic instability and need for future reoperation secondary to adjacent segment disease (ASD).…”

When to Consider Stand-Alone Lateral Lumbar Interbody Fusion: Is There a Role for a Comeback With New Implants?

“…Marchi reported a revision rate of 13.5% in 74 patients in a prospective, comparative single center study. 6,15 While there are potential benefits to stand-alone LLIF that have encouraged clinicians to use this approach to manage ASD, some complications should also be consid-In another study, Marchi et al tried to identify which patients may undergo the stand-alone procedure without cage subsidence and created a score with risk factors, considering age over 61, female gender, and the presence of spondylolisthesis and scoliosis as the main determinant factors. 16 With the technological advances and the less invasive approaches, at least 2 disruptive alternatives have emerged to make the posterior-based pedicle screw fixation additional to LLIF possible, without the need to flip the patient for a different decubitus: single-position surgery in lateral and prone position.…”

“…23 Overall, patient-related factors (bone quality, age older than 60 years, smoking status, high demand levels, female gender, spondylolisthesis, and scoliosis) and technicalrelated factors (intraoperative end plate violation, smaller cages, apophyseal ring contact of the implants, material of the cage, and type of graft used) combine to determine the outcomes of stand-alone LLIF. [5][6][7][10][11][12][13][14][15][16][17][18][19][20][21][22]…”