9:37 Circumferential lumbar spinal fusion with anterior lumbar interbody fusion Brantigan cage versus posterolateral fusion with titanium CD-Horizon: a prospective, randomized, clinical study of 146 patients

Abstract

Purpose of study: Circumferential fusion has become a common procedure in lumbar spine fusion both as a primary and as a salvage procedure. The present study documented that ALIF with Brantigan cage improves fusion rate and spinal sagittal alignment and removes pain originating from the disc. We have analyzed the effects of circumferential fusion using ALIF brantigan cages and titanium posterior instrumentation on functional outcome, fusion rate, complications and lumbar lordosis.Methods used: From April 1996 through November 1999, a total of 148 patients with severe chronic low back pain were randomly selected for either posterolateral lumbar fusion (PLF) with titanium CD-Horizon (posterolateral group) or circumferential fusion with ALIF Brantigan cage plus posterior instrumentation (ALF plus group). Dallas Pain Questionnaire (DPQ), Low Back Pain Rating Scale (LBPR) and a questionnaire concerning work status assessed their outcomes. Responses were registered preoperatively and at 1-and 2-year follow-ups.of findings: In both groups, 95% follow-ups at 1 and 2 years showed highly significant improvement in all four categories of life quality (DPQ) as well as in the back pain and leg pain index (LBPR) compared with preoperative status. There was a clear tendency toward better overall functional outcome for patients with the circumferential procedure (p<.08), and this patient group also experienced significantly less leg pain at 1-year follow-up (p<.03) and less peak back pain at 2 years (p<.04). There was no difference in admission days or blood loss, although operation time was significantly longer in the circumferential group. Sagittal lordosis was restored and maintained in the circumferential group (p<.01). Circumferential fusion patients showed a higher posterolateral fusion rate (92%) compared with the posterolateral group (80%; p<.04). The reoperation rate, including implant removal, was significantly lower in the circumferential group (7%; p<.002) versus that in the posterolateral group (22%) in the study period up to 5.5 years postoperatively. The overall study showed a significant correlation between fusion and good functional outcome.Relationship between findings and existing knowledge: To our knowledge, this is the first randomized prospective study to analyze a standardized spinal circumferential fusion procedure with a PLF procedure. Previous randomized controlled studies of supplemental pedicle screw instrumentation in PLF have not been able to show significant difference in clinical outcome between surgical methods. Our results have showed the patients with a circumferential fusion had a 92% union of the PLF mass and improved clinical outcome, significantly different from instrumented posterolateral fusion alone.Overall significance of findings: Circumferential lumbar fusion restored lordosis, provided a higher union rate with significantly fewer reoperations, showed a tendency toward better functional outcome and resulted in less peak back pain compared with instrumented PLF. However, circumferential fusion is a more extensive surgical procedure. The clinical perspective of our study implies a recommendation to favor circumferential fusion as a definitive surgical procedure in complex lumbar pathology involving major instability, flatback and previous disc surgery in younger patients compared with posterolateral fusion with pedicle screws alone.Disclosures: Device or drug: ALIF Brantigan cage. Status: investigational. Device or drug: titanium CDI. Status: approvedConflict of interest: Cody Bünger, grant research support.