Incidence and risk factors associated with superior-segmented facet joint violation during minimal invasive lumbar interbody fusion

Abstract

BACKGROUND CONTEXTThe trend of minimally invasive lumbar interbody fusion is increasing, and adjacent segmental degeneration (ASD) is one of the complications of the procedures in which facet joint violation (FJV) is a cause. FJVs can occur during percutaneous instrumentation. This study aimed to identify the risk factors that affect FJV during minimally invasive lumbar interbody fusion. PURPOSETo identify the risk factors for FJVs and the factors that have a strong impact on the violation. STUDY DESIGNRetrospective study. PATIENT SAMPLEPatients who underwent minimally invasive lumbar interbody fusion with percutaneous screw fixation between June 2018 and December 2019. OUTCOME MEASURESPrevalence of the FJV was reviewed by CT scans which obtained within 6 months after surgery, and the axial, coronal, and sagittal cuts of the scans were evaluated. The FJV was defined as the screw being visible in the facet joint in at least one plane of the CT scan. Radiographic parameters were measured using CT scans including diameters of the facet joints in the axial, coronal, and sagittal planes defined by the facet diameter. The facet angle (FA), the pedicle angle (PA), the screw-facet angle (SFA), the screw-endplate angle (SEA), and the superior margin of the facet joint in the sagittal plane (SD) differed from the head of the screw. At Last, the depth of back muscle was measured in the axial cut of the MRI. METHODSThis study analyzed 119 patients who underwent minimally invasive lumbar interbody fusion between June 2018 and December 2019. Facet joint violation at the uppermost level was examined using CT in all dimensions. Radiographic parameters (facet diameter, facet angle, pedicle angle, screw-facet angle, screw-endplate angle, and distance between the head of the screws and the facet) were measured. BMI, age, diagnosis, and navigation assistance were included in the study. Risk factors were analyzed to determine which factors had an effect on FJV, and the cut-off was calculated for each parameter. RESULTSThis study included 119 patients, with a mean age of 63 years. FJV occurred in 13/119 (10.9%) patients and 15/238 (6.3%) joints, respectively. No FJV occurred in 120 joints operated with navigation-assistance and 15/178 (8.4%) joints operated without navigation (p=.01). We found an increasing proportion of violations at more caudal levels: no violations occurred in eight patients with lumbar at L1 or L2, and 1/40 (2.5%), 7/158 (4.4%), and 7/32 (21.9%) of violations occurred at L3, L4, and L5, respectively (p=.01). The diameter of the facet in the axial cut, facet angle, screw facet angle, and distance between the head of the screw and facet were statistically significant in determining the increasing rate of FJV after multivariate analysis was performed (AROC=0.9486, p≤.05). The cutoff point for each radiographic parameter were diameter of facet in the axial ≥17.5 mm, diameter of facet in coronal plane ≥19.5 mm, facet angle ≥41.5o, screw-facet angle ≥39o, and distance between facet and the screw ≥-2.6 mm. The estimated probability of FJV was 96.9% when every parameter was greater than the cut-off point. CONCLUSIONSAn increase in the facet diameter in the axial plane, coronal plane, facet angle, screw facet angle, and the distance between the dome of the screw and facet are risk factors for FJV. Surgeons can avoid violations when radiographic considerations are done. Careful screw placement and good entry points for instrumentation may decrease the rate of facet violation.