Intraoperative Anteropulsion of an Interbody Fusion Cage During Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Report

Abstract

Expandable cages are very commonly used during minimally invasive lumbar interbody fusion surgery for better restoration of sagittal alignment. We present a rare event of intraoperative expandable cage anteropulsion into the retroperitoneal space. To date, several cases of cage migration have been reported. However, ours is the first case of intraoperative anterior cage migration during minimally invasive lumbar fusion. Herein, we present a case of 70-year-old female planned for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for grade II L5–S1 lytic spondylolisthesis. There was an unnoticed anterior longitudinal ligament rupture during the cage expansion manoeuvre. Cage dislodgment was noticed intraoperatively. This was managed by compression of the interbody site posteriorly and insertion of another snugly fitting bullet cage, followed by anterior retroperitoneal exploration in the same setting to retrieve the migrated cage. The patient’s postoperative course was satisfactory. At a 1-year follow-up, patient was ambulatory and asymptomatic. Follow-up imaging showed bony fusion and no signs of implant failure. Expandable TLIF cages can cause iatrogenic release of the anterior longitudinal ligament during expansion. Surgeons must be aware of this rare complication, which can result in anterior cage migration.