Multilevel Anterior Lumbar Interbody Fusion Research Articles

Comparison of patient outcomes of anterior and posterior lumbar interbody fusions: A retrospective national database analysis

BackgroundLumbar interbody fusions are used to treat degenerative lumbar disease unresponsive to conservative treatment. This procedure may be divided into anterior lumbar interbody fusion (ALIF), and posterior lumbar interbody fusion (PLIF/TLIF). Despite their widespread use, comparative research on their outcomes remains limited. MethodsThe PearlDiver Database was utilized to identify patients undergoing single and multi-level ALIF and PLIF/TLIF between 2010 and 2022. We examined demographic data, comorbidities, and reoperation rates at 90 days, 1 year, and 2 years. Complications were assessed using multivariable regression to adjust for confounders. ResultsThe study included multi-level anterior interbody fusions (N = 569, mean age 59.8, 59 % female), multi-level posterior interbody fusions (N = 43,651, mean age 57.9, 60 % female), single-level anterior interbody fusions (N = 3,547, mean age 55.3, 61 % female) and single-level posterior interbody fusions (N = 25,792, mean age 56.9, 62 % female). Multi-level posterior interbody fusion patients had a lower prevalence of HTN (OR .77, P < .05), ischemic heart disease (OR .73, P < .05), CDK (OR .77, P < .05), postoperatively more DVTs (OR 1.44, P < .05), a lower incidence of respiratory failure (OR .57, P < .05), and a higher 90-day, 1-year, and 2-year all-cause reoperation rate (7.3 %) compared to multi-level anterior interbody fusion patients (3.7 %). Single-level posterior interbody fusion patients had more HTN (OR 1.1, P < .05), less ischemic heart disease (OR .89, P < .05), obesity (OR .92, P < .05), and postoperatively a higher incidence of DVT (OR 1.34, P < .05) but lower 90-day, 1-year, and 2-year all-cause reoperation rates. ConclusionsThis study confirms that posterior interbody fusions are more common than anterior procedures, though the latter is increasing. Reoperation rates are higher for multi-level posterior and single-level anterior fusions. Both anterior and posterior approaches show similar complication profiles, though specific risks, such as postoperative DVT, vary. These findings emphasize the need for ongoing research and consideration of individual patient factors when choosing an interbody fusion technique.

Outcomes and Spinopelvic Changes After Anterior Lumbar Interbody Fusion With a Novel Interbody Fusion Device: A Retrospective Study.

Interbody devices in anterior lumbar interbody fusion (ALIF) are currently a focus of innovation due to their potential to improve clinical outcomes. The purpose of the present study was to analyze complications and changes in spinopelvic parameters after ALIF with the novel Medacta MectaLIF interbody fusion device. Patients aged 18 to 80 years who underwent multilevel ALIF using this novel implant were identified. Demographic and surgical data were collected. Patients were divided into short- and long-fusion cohorts. A comparison of outcomes between the short- and long-fusion groups was performed using the Student t test for continuous variables and Fisher's exact test and the χ2 test for categorical variables. Analysis of the pre- vs postoperative radiographic data for the entire cohort was performed using the 2-tailed Student t test. One hundred and eight patients met the inclusion criteria. No significant postoperative change was observed in L1-4 lumbar lordosis (LL). L1-S1 LL increased to a mean of 55.1 ± 12.8 (a mean change of 10.7 ± 14.5), and L4-S1 LL increased to a mean of 38.4 ± 8.7 (a mean increase of 7.5 ± 8.2), with pelvic incidence LL mismatch changing from 8.9 ± 15.1 to 1.1 ± 13.5 (n = 102). Related changes in sacral slope and pelvic tilt were also observed (33.0 ± 11.0 to 37.6 ± 10.9 and 19.6 ± 9.5 to 18.2 ± 9.1 [n = 103], respectively). Five patients (4.6%) experienced implant subsidence, 1 (0.9%) had implant migration, and 6 (5.6%) experienced a nonunion. There was no difference in the rates of complications associated with the novel implant in the short- and long-fusion cohorts. This novel implant achieves correction of spinopelvic parameters with minimal complications. The ability to modify the implant intraoperatively based on the patient's anatomy can help achieve maximal contact area and therefore help reduce the risk of subsidence. This modular implant can achieve correction of spinopelvic parameters with minimal medical and surgical complications.

Risk factors for vascular injuries in anterior lumbar interbody fusion: a single-institution retrospective study.

Vascular injuries in anterior lumbar interbody fusion (ALIF) occur due to the vascular manipulation needed to achieve optimal disc space exposure. In this study, the authors aimed to evaluate intraoperative vascular injuries in patients undergoing single- and multilevel ALIF at a large tertiary academic center. Prospectively collected data specifically addressing postoperative complications in patients who underwent ALIF by neurosurgery spine faculty working with a specialized vascular surgeon were retrospectively reviewed. Demographic characteristics and intraoperative data were collected. Patients were split into vascular injury and non-vascular injury groups. Outcome comparisons were conducted using the chi-square exact and Wilcoxon rank-sum tests for categorical and continuous data, respectively. Logistic regression was used to investigate associations with vascular injury, with univariate analysis first conducted to identify candidate associations. Based on these results, variables demonstrating a between-groups test statistic of p < 0.10 were included in the multivariate analysis to determine the independent predictors of vascular injuries. In total, 323 patients who underwent ALIF procedures were identified: 51% were male (n = 166) and 49% were female (n = 157). The mean age was 57.1 years, with 56% (n = 182) having undergone prior lumbar surgery. Vascular injuries were encountered intraoperatively in 7.1% (n = 23) of patients, and the majority (91% [n = 21]) involved the left common iliac vein. Patients with vascular injuries were statistically older (mean 63.6 vs 56.6 years), had greater incidence rates of coronary artery disease, opioid use, multilevel ALIF surgery involving the L2-3 level, and surgery involving multiple disc spaces, had more multilevel anterior instrumentation, and experienced greater blood loss during surgery and longer length of stay (all p < 0.05). Overall, there was 1 death (0.3%) secondary to aortic artery injury. Multivariate analysis identified opioid use, multilevel ALIF involving L2-3, and multiple interbodies as statistically independent predictors of vascular injury (all p < 0.05). Identifying patient risk factors can reduce the risk of vascular injuries in ALIF. Opioid use, multilevel ALIF involving L2-3, and multiple interbodies were independent predictors of vascular injuries in ALIF.

Pedicle Subtraction Osteotomy Versus Multilevel Anterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in the Treatment of Adult Spinal Deformity: Trends, Outcomes, and Cost.

Retrospective cohort study. The aim of this study was to compare the outcomes of pedicle subtraction osteotomy (PSO) with multilevel anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) in posterior long-segment fusion. PSO and ALIF/LLIF are 2 techniques used to restore lumbar lordosis and correct sagittal alignment, with each holding its unique advantages and disadvantages. As there are situations where both techniques can be employed, it is important to compare the risks and benefits of both. Patients aged 18 years or older who underwent PSO or multilevel ALIF/LLIF with posterior fusion of 7-12 levels and pelvic fixation were identified. 1:1 propensity score was used to match PSO and ALIF/LLIF cohorts for age, sex, and relevant comorbidities, including smoking status. Logistic regression was used to compare medical and surgical outcomes. Trends and costs were generated for both groups as well. ALIF/LLIF utilization in posterior long fusion has been steadily increasing since 2010, whereas PSO utilization has significantly dropped since 2017. PSO was associated with an increased risk of durotomy ( P < 0.001) and neurological injury ( P = 0.018). ALIF/LLIF was associated with increased rates of postoperative radiculopathy ( P = 0.005). Patients who underwent PSO had higher rates of pseudarthrosis within 1 and 2 years ( P = 0.015; P = 0.010), 1-year hardware failure ( P = 0.028), and 2-year reinsertion of instrumentation ( P = 0.009). Reoperation rates for both approaches were not statistically different at any time point throughout the 5-year period. In addition, there were no significant differences in both procedural and 90-day postoperative costs. PSO was associated with higher rates of surgical complications compared with anterior approaches. However, there was no significant difference in overall reoperation rates. Spine surgeons should select the optimal technique for a given patient and the type of lordotic correction required.

Abdominal lymphocele following multi-level anterior lumbar interbody fusion (ALIF) managed with a laparoscopic peritoneal window: case report and review of the literature

PurposeLymphocele formation following anterior lumbar interbody fusion (ALIF) is not common, but it can pose diagnostic and treatment challenges. The purpose of this case is to report for the first time the treatment of a postoperative lymphocele following a multi-level ALIF using a peritoneal window made through a minimally invasive laparoscopic approach.MethodsCase report.ResultsA 74-year-old male with a history of prostatectomy and pelvic radiation underwent a staged L3–S1 ALIF (left paramedian approach) and T10-pelvis posterior instrumented with L1–5 decompression/posterior column osteotomies for degenerative scoliosis and neurogenic claudication. Three weeks after surgery, swelling of the left abdomen and entire left leg was reported. Computed tomography of the abdomen/pelvis demonstrated a large (19.2 × 12.0 × 15.4 cm) retroperitoneal fluid collection with compression of the left ureter and left common iliac vein. Fluid analysis (80% lymphocytes) was consistent with a lymphocele. Percutaneous drainage for 4 days was ineffective at clearing the lymphocele. For more definitive management, the patient underwent an uncomplicated laparoscopic creation of a peritoneal window to allow passive drainage of lymphatic fluid into the abdomen. Three years after surgery, he had no back or leg pain, had achieved spinal union, and had no abdominal swelling or left leg swelling. Advanced imaging also confirmed resolution of the lymphocele.ConclusionsIn this case report, creation of a peritoneal window minimally invasively via a laparoscope allowing passive drainage of lymphatic fluid into the abdomen was safe and effective for management of an abdominal lymphocele following a multi-level ALIF.

Minimally invasive lateral single-position surgery for multilevel degenerative lumbar spine disease: feasibility and perioperative results in a single Latin-American spine center.

Within advances in minimally invasive spine surgery, the implementation of lateral single position (LSP) increases efficiency while limiting complications, avoiding intraoperative repositioning and diminishing surgical time. Most literature describes one-level instrumentation of the lumbar spine; this study includes the use of LSP for multilevel degenerative disease. The objective of the article is to analyze initial clinical results and complications in the use of LSP for multiple level instrumentation in adults with lumbar degenerative disease. A retrospective early clinical series was performed for patients who had multiple level instrumentation in LSP between August 2019 and September 2022 at the Hospital Universitario San Ignacio in Bogota, Colombia. Inclusion criteria were patients older than 18years with symptomatic lumbar degenerative disease, undergoing any combination of multilevel anterior lumbar interbody fusion, lateral lumbar interbody fusion (LLIF) and pedicle screw fixation. Forty patients with an average age of 61.3years were included, with diagnosis of multilevel degenerative spondylotic changes. Four-, three- and two-level interventions were performed in 52.5, 35 and 12.5%, respectively. Average time per level was 68.9min, and length of hospital stay had an average of 2.4days, with all patients starting ambulation within the first postoperative day. Procedural time and blood loss were similar to those reported in literature. No severe lesions, postoperative infections or reinterventions took place. Although it was a small number of patients and further clinical trials are needed, LSP for multiple levels is apparently safe with adequate outcomes which may improve efficiency in the operating room.

Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion: No Increased Complications.

Retrospective cohort study. The aim were to (1) evaluate differences in postoperative outcomes and cost associated with outpatient anterior lumbar interbody fusion (ALIF) compared with inpatient ALIF, and to (2) identify independent factors contributing to complications after outpatient ALIF. While lumbar fusion is traditionally performed inpatient, outpatient spinal surgery is becoming more commonplace as surgical techniques improve. The study population included all patients below 85 years of age who underwent elective ALIF (CPT-22558). Patients were then divided into those who underwent single-level fusion and multilevel fusion using the corresponding additional level fusion codes (CPT-22585). These resulting populations were then split into outpatient and inpatient cohorts by using a service location modifier. To account for selection bias, propensity score matching was performed; the inpatient cohorts were matched with respect to the outpatient cohorts based on age, sex, and Charlson Comorbidity Index. Statistical significance was set at P<0.05 and the Bonferroni correction was used for each multiple comparison (P<0.004). Patients undergoing outpatient procedure had decreased rates of medical complications following both single-level and multilevel ALIF. In addition, age above 60, female sex, Charlson Comorbidity Index>3, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, hypertension, and tobacco use were all identified as independent risk factors for increased complications. Finally, the cost of outpatient ALIF was $12,013 while the cost of inpatient ALIF was $27,271 (P<0.001). The findings add to the growing body of literature advocating for the utilization of ALIF in the outpatient setting for a properly selected group of patients. Level IV.

Outpatient Versus Inpatient Anterior Lumbar Spine Surgery: A Multisite, Comparative Analysis of Patient Safety Measures.

The frequency and complexity of spinal surgery performed in an ambulatory surgery center (ASC) is increasing. However, safety and efficacy data of most spinal procedures adapted to the ASC are sparse and have focused on anterior cervical surgery. The purpose of this study was to compare the 90-day complication and readmission rates of anterior lumbar spine surgery performed in an ASC or inpatient setting. We performed a retrospective comparative analysis of 226 consecutive anterior lumbar surgeries (283 levels treated) completed in an ASC (n = 124) or in an inpatient tertiary care hospital (n = 102) over a 3-year period. These included anterior lumbar interbody fusion (ALIF), artificial disc replacement (ADR), and hybrids. Patients undergoing simultaneous or staged posterior procedures within 3 months were excluded. Patient demographics and surgical parameters between the two surgical settings were compared. Ninety-day medical complications and readmission rates were assessed. One-way analysis of variance and Chi-square analysis were used. A P value of less than .05 was considered statistically significant. The two study groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations, and readmissions for the ASC cohort, the differences were not statistically significant. There were 7 intraoperative complications (5.6% minor vascular injury) in the inpatient cohort and 0 in the ASC cohort. The overall 90-day postoperative complication rate was 5.6% for the inpatient cohort and 0.9% for the ASC cohort. The 90-day readmission rate was 1.9% in the ASC cohort and 1.6% in the inpatient cohort. The 90-day reoperation rate was 0.8% for the inpatient cohort and 0% in the ASC cohort. The average hospital stay was 2.3 ± 1.5 days for the inpatient cohort. The 90-day readmission rates were lower for outpatients than for inpatients, while the complication and reoperation rates were similar. Our results demonstrate that anterior lumbar procedures, including single-level and multilevel ALIF, ADR, and hybrid procedures, can be performed safely in an ASC. This has significant cost savings implications for the ASC setting.

Is it sufficient to treat adult lumbar spinal deformity using anterior lumbar interbody fusion with percutaneous pedicle screw fixation?

Anterior lumbar interbody fusion (ALIF) has been performed for lumbar spinal restoration and stabilization without extensive paraspinal muscle damage or massive bleeding. The authors retrospectively investigated surgical results of multilevel ALIF followed by percutaneous pedicle screw fixation (PPSF) in adult lumbar spinal deformity (ALSD). This study included 28 patients with degenerative lumbar spinal deformity, who underwent selective multilevel ALIF and PPSF between January 2013 and August 2016 at our hospital. Standing X-rays were performed and coronal Cobb angle (CCA) of scoliosis, sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), and sacral slope (SS) were measured. Pain and functional assessment were performed using visual analogue scale (VAS) scores for low back pain and leg pain, and Oswestry Disability Index (ODI) scores. CCA, SVA and LL were significantly improved immediately after surgery and relatively well maintained until the last follow-up. After surgery, PT was significantly decreased and SS was increased, respectively. However, cases with SVA > 95 mm or PT > 30° showed a loss of correction in sagittal balance parameters to a greater extent at the last follow-up compared to the group of patients with minor sagittal imbalance. VAS scores for back and radicular pain, and ODI score were significantly decreased at the final follow-up (p < 0.05). Multilevel ALIF with PPSF yielded favorable clinical and radiological outcomes in coronal and sagittal balance without severe surgical mortality or morbidity in patients with ALSD. However, correction loss in sagittal balance was observed in cases with SVA > 95 mm or PT > 30˚.

243. Predictors of inpatient admission in the setting of anterior lumbar interbody fusion

BACKGROUND CONTEXT While the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications has hindered transition to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of greater than 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist developing screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting. PURPOSE The purpose of this study is to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF. STUDY DESIGN/SETTING Retrospective PATIENT SAMPLE A total of 135 patients who underwent single or multilevel ALIF. OUTCOME MEASURES Postoperative complications, postoperative fever, blood transfusion, cardiovascular complications, longer inpatient stay METHODS A prospectively maintained surgical registry was reviewed for patients undergoing single or multi-level ALIF between May 2006 and September 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their elevation of relative risk (RR) of an inpatient stay ≥ 24 hours. A Poisson regression model evaluated predictors of inpatient stays ≥ 24 hours. A stepwise backward regression model identified risk factors for inpatient admission of greater than or equal to 24 hours. RESULTS A total of 135 patients underwent single or multilevel ALIF. 53% of the cohort was female and 54.8% was ≤50 years of age. Nine (6.7%) patients were discharged in less than 24 hours and 126 remained admitted for ≥24 hours. The average inpatient stay was two days. The most common postoperative complication was a temperature ≥100.4°F (n=5, 3.8%). Other complications included blood transfusions (n=4, 3.0%) and cardiovascular complications (n=3, 2.2%). Bivariate analysis revealed that having a multilevel procedure on L4L5 and either L3L4 or L5S1 (RR=1.07 or 1.09, p=0.003) had the largest RR elevation for an inpatient stay of ≥ 24 hours. Stepwise multivariate analysis of risk factors revealed foraminal stenosis (RR=0.84, P=0.045), degenerative disc disease (RR=1.25, P=0.028), estimated blood loss >50 mL (RR=1.25, P=0.011), and BMI ≥30 kg/m2 (RR=1.16, p=0.030) to be significant predictors for inpatient stays of ≥24 hours. CONCLUSIONS Our study provides an incidence of demographics, perioperative characteristics, and postoperative complications as they pertain to patients undergoing ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Anterior lumbar compared to oblique lumbar interbody approaches for multilevel fusions to the sacrum in adults with spinal deformity and degeneration.

In adult spinal deformity and degenerative conditions of the spine, interbody fusion to the sacrum often is performed to enhance arthrodesis, induce lordosis, and alleviate stenosis. Anterior lumbar interbody fusion (ALIF) has traditionally been performed, but minimally invasive oblique lumbar interbody fusion (OLIF) may or may not cause less morbidity because less retraction of the abdominal viscera is required. The authors evaluated whether there was a difference between the results of ALIF and OLIF in multilevel anterior or lateral interbody fusion to the sacrum. Patients from 2013 to 2018 who underwent multilevel ALIF or OLIF to the sacrum were retrospectively studied. Inclusion criteria were adult spinal deformity or degenerative pathology and multilevel ALIF or OLIF to the sacrum. Demographic, implant, perioperative, and radiographic variables were collected. Statistical calculations were performed for significant differences. Data from a total of 127 patients were analyzed (66 OLIF patients and 61 ALIF patients). The mean follow-up times were 27.21 (ALIF) and 24.11 (OLIF) months. The mean surgical time was 251.48 minutes for ALIF patients and 234.48 minutes for OLIF patients (p = 0.154). The mean hospital stay was 7.79 days for ALIF patients and 7.02 days for OLIF patients (p = 0.159). The mean time to being able to eat solid food was 4.03 days for ALIF patients and 1.30 days for OLIF patients (p < 0.001). After excluding patients who had undergone L5-S1 posterior column osteotomy, 54 ALIF patients and 41 OLIF patients were analyzed for L5-S1 radiographic changes. The mean cage height was 14.94 mm for ALIF patients and 13.56 mm for OLIF patients (p = 0.001), and the mean cage lordosis was 15.87° in the ALIF group and 16.81° in the OLIF group (p = 0.278). The mean increases in anterior disc height were 7.34 mm and 4.72 mm for the ALIF and OLIF groups, respectively (p = 0.001), and the mean increases in posterior disc height were 3.35 mm and 1.24 mm (p < 0.001), respectively. The mean change in L5-S1 lordosis was 4.33° for ALIF patients and 4.59° for OLIF patients (p = 0.829). Patients who underwent multilevel OLIF and ALIF to the sacrum had comparable operative times. OLIF was associated with a quicker ileus recovery and less blood loss. At L5-S1, ALIF allowed larger cages to be placed, resulting in a greater disc height change, but there was no significant difference in L5-S1 segmental lordosis.

Anterior lumbar interbody fusions combined with posterior column osteotomy in patients who had sagittal imbalance associated with degenerative lumbar flat-back deformity: a retrospective case series.

Anterior lumbar interbody fusion (ALIF) combined with posterior column osteotomy (PCO) may be effective to achieve ideal lumbar curve correction in lumbar flat-back deformity (LFD). We aimed to investigate the radiographic and clinical outcomes of patients with primary degenerative LFD treated with multi-level ALIFs combined with PCOs. Seventy patients with primary degenerative LFD who underwent corrective surgery were divided into three groups according to the 1-month postoperative pelvic incidence/lumbar lordosis (PI-LL) angles (≤ - 10°, from - 9° to 9°, and ≥ 10°). The spinopelvic parameters, including thoracic kyphosis, LL, pelvic tilt, T1 pelvic angle, and sagittal vertical axis, were analyzed at the preoperative, postoperative follow-up periods. The clinical outcomes, including the Oswestry disability index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22r, were also evaluated. Further, the paraspinal muscles were qualitatively and quantitatively examined, preoperatively. All spinopelvic parameters were corrected as close to the normal values at the 1-month postoperative period. The spinopelvic parameters in the PI-LL ≤ - 10° group were better corrected and maintained than those in the other groups. The ODI, VAS, and SRS-22r scores improved at the final follow-up in all groups. The PI-LL ≤ - 10° group showed better clinical outcomes than the other groups. In the paraspinal muscle examination, the mean lumbar muscularity value and fatty degeneration ratio were 236.7% and 20.7%, respectively. Multi-level ALIFs with PCOs in patients with LFD are effective in restoring sagittal balance and improving clinical symptoms. In addition, the postoperative LL angles should be larger than PI + 10° to achieve good overall outcomes in patients with severe degenerative back muscle.

Incidence of Respiratory Complications Following Lumbar Spine Surgery.

The purpose of this study is to assess the incidence, risk factors for, and types of respiratory complications occurring in patients undergoing lumbar spine surgery. Patients undergoing various lumbar spine surgeries from 2007 to 2014 were identified using the PearlDiver patient record database from the nationwide insurance provider Humana Inc. Patient records were analyzed using International Classification of Diseases, Ninth Revision codes and Current Procedural Terminology codes to determine the incidence of pneumonia, pleural effusion, pulmonary collapse, and acute respiratory failure for each procedure type. The incidence of these complications in patients with the risk factors diabetes mellitus, chronic obstructive pulmonary disease (COPD), and smoking was also examined. A total of 64,891 patients (33,280 females; 31,611 males) within the Humana database underwent various lumbar procedures from 2007 to 2014. The overall incidence of respiratory complications in patients undergoing lumbar procedures was 5.7% (n = 3694) within 1 month of having the procedure. Pulmonary collapse was the most common complication with an incidence of 4.3% (n = 2792), followed by pneumonia 1.98% (n = 1285), acute respiratory failure 1.97% (n = 1279), and pleural effusion 1.6% (n = 1048). For each respiratory complication studied, single level discectomy had the lowest complication rate and multilevel anterior lumbar interbody fusion had the highest complication rate. The incidence of each individual respiratory complication was higher in patients who had a history of smoking, COPD, or diabetes mellitus than it was in patients with none of these 3 risk factors (P < .01). The results of this study show that patients who have a history of smoking, COPD, or diabetes mellitus are at a greater risk for respiratory complications following lumbar spine surgery. These findings are useful for patient selection, clinical decision-making, and preoperative counseling.

360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity.

Study Design:Retrospective cohort study.Objective:To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF).Methods:Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample t test and repeated-measures analysis of variance (rANOVA), was performed.Results:Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively (P < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years (P < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years (P < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years (P = .02). There were no neurological, vascular, or visceral approach–related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture.Conclusions:The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.

Artrodese lombar intersomática anterior multinível combinada com estabilização posterior em discopatia – Análise clínico‐funcional prospectiva

ObjectiveThis was a prospective controlled study in patients with lumbar degenerative disc disease submitted to instrumented anterior lumbar interbody fusion combined with posterior stabilization. MethodsSample with 64 consecutive patients operated by the same surgeons over four years. Half of the anterior lumbar interbody fusion were at two levels, 43.8% at three levels, and 6.25% at one level. The authors stand‐alone interbody cages with integrated screws, filled with bone matrix and bone morphogenetic protein 2. ResultsHalf of the sample had previous lumbar spine surgeries, 75% had associated degenerative listhesis, and 62.5% had posterior lumbar compression disease. Approximately 56% of the sample had at least one nonunion risk factor. The Oswestry index changed from 71.81 ± 7.22 at the preoperative assessment to 24.75 ± 7.82 at the final follow‐up evaluation, while the visual analog pain scale changed from 7.88 ± 0.70 to 2.44 ± 0.87 (p < 0.001). Clinical and functional improvements were better according to the intervention performed in a higher number of levels, proving multilevel anterior lumbar interbody fusion efficacy, which was performed in 93.75% of the sample. The global complication rate was 7.82%, and the major complications rate was 0%. No cases of non‐union were observed. ConclusionInstrumented anterior lumbar interbody fusion combined with posterior stabilization is a successful option for uni‐ and multilevel degenerative disc disease of L3 to S1, even in significant presence of the risk factors of nonunion and previous lumbar surgeries, guarantying very satisfactory clinical functional and radiographic outcomes, with a low complications rate over the medium term.

5 - A novel approach to the thoracolumbar spine to s1 using visceral rotation to perform multilevel anterior lumbar interbody fusion (ALIF) for sagittal balance correction

5 - A novel approach to the thoracolumbar spine to s1 using visceral rotation to perform multilevel anterior lumbar interbody fusion (ALIF) for sagittal balance correction

Arthrodesis Rate and Patient Reported Outcomes After Anterior Lumbar Interbody Fusion Utilizing a Plasma-Sprayed Titanium Coated PEEK Interbody Implant: A Retrospective, Observational Analysis.

Anterior lumbar interbody fusion (ALIF) is utilized in symptomatic spinal disc destabilization due to degenerative lumbar disc disease, isthmic and degenerative spondylolisthesis, internal disc disruption, or pseudarthrosis after non-operative treatments fail. The addition of a plasma-sprayed titanium coating (PTC) to polyether ether ketone spacers (PEEK) may reduce the rate of implant subsidence or non-union secondary to poor osseous-integration of non-coated PEEK or metal interbody systems. A retrospective, non-randomized, single-center chart review, evaluated the post-surgical follow-up data of patients receiving a PTC PEEK implant during single or multi-level ALIF procedures to determine the clinical efficacy and rate of arthrodesis after utilization of a coated spacer. Standard roentgenographs or computed tomography were used to identify successful arthrodesis following the ALIF procedure and longitudinal clinical improvements were determined by scores on the Visual Analog Scale (VAS) for low back and leg pain. Forty-four subjects (48% male, mean=53 years) were included in this chart review. Follow-up radiology demonstrated radiographic union with bridging bone formation across the interbody space for 42/44 (96%) individuals with solid arthrodesis occurring at an average of 7.3 ± 2.3 months. Subjects demonstrated significant improvement in VAS low back pain (4.5 ± 2.4 point improvement, p=0.0001) and VAS leg pain (4.1 ± 3.3 point improvement, p=0.0001). While there was a significant reduction in the improvement of VAS low back pain of Worker's Compensation claimants as compared to other patients (3.9 ± 2.4 vs. 5.3 ± 2.1), there was no difference in VAS low back pain or leg pain when the data was stratified by gender, age, tobacco use, comorbidities, prior surgery, fusion construct length, use of supplemental posterior instrumentation, BMI, or diagnosis. This study provides support that the addition of a PTC coating to a zero-profile PEEK lumbar interbody spacer facilitates rapid and stable fixation at the bone-implant interface. This facilitated osteogenesis is associated with significantly improved pain outcomes, low implant subsidence and a high definitive rate of arthrodesis. Future studies should include a prospective, randomized, controlled, multi-center approach to directly compare arthrodesis rates and clinical outcomes longitudinally between standard PEEK and biomaterial-coated PEEK interbody spacer systems.

Effect of Anatomic Variability and Level of Approach on Perioperative Vascular Complications With Anterior Lumbar Interbody Fusion.

Retrospective review of prospectively collected data. The study aim was to determine the prevalence of vascular complications associated with anterior lumbar interbody fusion (ALIF) as a function of anatomic variation and the number of levels fused. ALIF often requires mobilization of the great vessels, particularly when exposing levels above L5-S1. The exposure can be more challenging in the setting of spondylolisthesis or transitional anatomy. This retrospective review of prospectively collected data from our spine database identified 204 patients who had undergone single level (n = 142) or multilevel (n = 62) ALIF from 2008 to 2013 with minimum 6-month follow-up. Average age was 58 years; 57% were female. Preoperative radiographic assessment for spondylolisthesis and transitional anatomy was performed. Body mass index, estimated blood loss, and levels of ALIF were recorded. Intraoperative vascular injury, postoperative deep venous thrombosis, and pulmonary embolism events were noted. Eleven patients experienced postoperative thromboembolic events and were more likely to have had intraoperative vascular injury compared with patients who did not develop a vascular complication (36% and 5%, respectively; P = 0.004). Estimated blood loss was significantly higher in patients with spondylolisthesis when compared to patients without spondylolisthesis (520 cc vs. 103 cc, respectively; P = 0.017) or transitional anatomy (347 cc vs. 262 cc, respectively; P = 0.022). Patients undergoing multilevel ALIF had significantly higher blood loss than patients undergoing a single level procedure (684 cc vs. 107 cc; P < 0.001). Patient characteristics, blood loss, anatomic variation, and level of approach were not associated with the development of postoperative thromboembolic complications. Performing ALIF in the setting of spondylolisthesis or transitional anatomy resulted in higher blood loss. Patients undergoing multilevel rather than single level ALIF experienced greater blood loss. Because patients with intraoperative vascular injury had increased likelihood of postoperative thromboembolic event, thrombosis prophylaxis should be considered in these patients. 4.

Clinical outcomes and fusion rates following anterior lumbar interbody fusion with bone graft substitute i-FACTOR, an anorganic bone matrix/P-15 composite.

Despite limited availability and the morbidity associated with autologous iliac crest bone graft (ICBG), its use in anterior lumbar interbody fusion (ALIF) procedures remains the gold standard to achieve arthrodesis. The search for alternative grafts yielding comparable or superior fusion outcomes with fewer complications continues. In particular, i-FACTOR, a novel bone graft substitute composed of anorganic bone matrix (ABM) with P-15 small peptide, is one example currently used widely in the dental community. Although preclinical studies have documented its usefulness, the role of i-FACTOR in ALIF procedures remains unknown. The authors' goal was to determine the safety and efficacy of i-FACTOR bone graft composite used in patients who underwent ALIF by evaluating fusion rates and clinical outcomes. A nonblinded cohort of patients who were all referred to a single surgeon's practice was prospectively studied. One hundred ten patients with degenerative spinal disease underwent single or multilevel ALIF using the ABM/P-15 bone graft composite with a mean of 24 months (minimum 15 months) of follow-up were enrolled in the study. Patient's clinical outcomes were assessed using the Oswestry Disability Index for low-back pain, the 12-Item Short Form Health Survey, Odom's criteria, and a visual analog scale for pain. Fine-cut CT scans were used to evaluate the progression to fusion. All patients who received i-FACTOR demonstrated radiographic evidence of bony induction and early incorporation of bone graft. At a mean of 24 months of follow-up (range 15-43 months), 97.5%, 81%, and 100% of patients, respectively, who had undergone single-, double-, and triple-level surgery exhibited fusion at all treated levels. The clinical outcomes demonstrated a statistically significant (p < 0.05) difference between preoperative and postoperative Oswestry Disability Index, 12-Item Short Form Health Survey, and visual analog scores. The use of i-FACTOR bone graft substitute demonstrates promising results for facilitating successful fusion and improving clinical outcomes in patients who undergo ALIF surgery for degenerative spinal pathologies.

Biomechanical comparison of supplemental posterior fixations for two-level anterior lumbar interbody fusion

Posterior instrumentations have been used to supplement anterior lumbar interbody fusion with cages. Biomechanical studies on single-level anterior lumbar interbody fusion show that stand-alone cages supplemented with posterior translaminar facet or transfacet screw fixation exhibit comparable stability to those supplemented with pedicle screw/rod fixation, while stability of multilevel anterior lumbar interbody fusion remains mostly unknown. The objectives of this study are to compare the stabilization of three supplemental posterior fixations to two-level anterior lumbar interbody fusion, including translaminar facet fixation, transfacet screw fixation, and pedicle screw/rod fixation. Flexibility tests were conducted on fresh-frozen calf spines with moment up to 8.5 N m in flexion, extension, lateral bending, and axial rotation. Each specimen was tested at three stages: intact, anterior lumbar interbody fusion using Polyetheretherketone (PEEK) interbody cage at L3-L4 and L4-L5, and the same anterior lumbar interbody fusion plus one of the three supplemental posterior fixations. The addition of the supplemental posterior fixation increased stiffness at the fusion levels significantly in flexion (9.9 times), extension (5.4 times), and lateral bending (4.1 times). The pedicle screw/rod and translaminar screw fixations provide approximately 40% higher stiffness than the transfacet screw in lateral bending. The pedicle screw/rod fixation also displayed a trend of superior fixation in extension. Supplemental posterior fixation significantly improved stability of two-level anterior lumbar interbody fusion when compared to the stand-alone cages. Pedicle screw/rod system is still the "gold standard" in providing supplemental stability. However, both translaminar facet screws and transfacet screws are good alternatives to provide adequate fixation.