Multilevel Posterior Lumbar Interbody Fusion Research Articles

Comparison of transforaminal and posterior lumbar interbody fusion outcomes in patients receiving a novel allograft versus rhBMP-2: a radiographic and patient-reported outcomes analysis.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been demonstrated to achieve the highest rates of arthrodesis in multilevel lumbar fusion but is also associated with possible perioperative morbidity. A novel allograft (OSTEOAMP) is a differentiated allograft that retains growth factors supporting bone healing. The authors sought to compare the clinical and radiographic outcomes of rhBMP-2 and the novel allograft in lumbar interbody arthrodesis to determine if the latter may be a safer and equally effective alternative to rhBMP-2 for single- and multilevel posterior or transforaminal lumbar interbody fusion (PLIF or TLIF). Patients who underwent single- or multilevel TLIF or PLIF using either OSTEOAMP or rhBMP-2 at the authors' institution over a 2-year period were prospectively followed for 12 months. Healthcare utilization, safety measures, patient satisfaction, physical disability (measured on the Oswestry Disability Index [ODI]), back and leg pain (on the numeric rating scale [NRS]), quality of life (on the EQ-5D scale), and return to work (RTW) were prospectively recorded. For purposes of this study, this consecutive series was retrospectively analyzed and pseudarthrosis rates were assessed at 2 years of follow-up. All patients (100%) had both 12-month patient-reported outcome follow-up and 24-month clinical and radiographic follow-up. One thousand one hundred fifty-four patients (654 treated with OSTEOAMP, 500 with rhBMP-2) were prospectively enrolled in the institutional registry. After propensity score matching, there were no significant baseline differences between 330 novel allograft and 330 rhBMP-2 cases. Perioperative morbidity and 90-day hospital readmission (3.3% vs 2.4%, p = 0.485) did not significantly differ between the novel allograft and the rhBMP-2 cases. At the 2-year follow-up, symptomatic pseudarthrosis requiring revision surgery occurred in 8 patients (2.4%) with OSTEOAMP and 6 patients (1.8%) with rhBMP-2 (p = 0.589). The overall fusion rate at 2 years was similar between groups (p = 0.213). Both groups showed significant and equivalent improvement in patient-reported outcome measures (PROMs) from baseline to 12-month follow-up, with no significant difference in 1-year mean NRS leg pain score (2.5 vs 2.7), ODI (25 vs 26), quality-adjusted life years (0.73 vs 0.73), satisfaction (83% vs 80%), or RTW (6.6 vs 7 weeks). In the authors' institutional experience, OSTEOAMP is a clinically viable substitute for rhBMP-2 for single- and multilevel lumbar fusion. This novel allograft provides clinically effective arthrodesis and improvements in PROMs comparable to rhBMP-2 with a similar safety profile. Additional indications and outcome assessment in longitudinal studies are needed to further characterize this allogeneic graft.

Effectiveness of intraoperative table modification for achieving lumbar lordosis in multilevel lumbar fusion surgery: a propensity score-matched study

Background In multilevel posterior lumbar interbody fusion (PLIF) with posterior screw fixation, obtaining sufficient lumbar lordosis (LL) is difficult, especially in patients with osteoporosis. We performed intraoperative table modification (TM) using gravitational dropping of the patient’s lumbar spine, to improve restoration of LL. Methods We retrospectively reviewed the medical records of patients who underwent three- or four-level PLIF between 2005 and 2019. One hundred eleven patients were enrolled, with 96 patients receiving non-TM-PLIF and 15 patients receiving TM-PLIF. Radiological parameters, including segmental lordosis (SL), LL, sacral slope (SS), pelvic incidence, and pelvic tilt, were measured. Clinical outcomes were measured using a visual analogue scale (VAS) for the back and leg preoperatively and at the last follow-up. Additionally, the correlation between the bone mineral density (BMD) and the radiological parameters was calculated for TM-PLIF. We performed propensity score matching between the groups to control the baseline difference. Results We found a statistically better correction between immediate and last follow-up postoperative SL (p = 0.04), as well as between preoperative and last follow-up SL (p < 0.01) in the TM-PLIF group compared to that in the non-TM-PLIF group. VAS for the back and leg were not significantly different between the two groups. Additionally, the efficacy of lordosis correction in the TM-PLIF group showed a statistically significant negative correlation between BMD and the SS change both before and after the surgery (rho = −0.60, p = 0.02). Conclusion Whilst further study is required to conclusively establish its efficacy, TM-PLIF (table modification using gravitational dropping) shows potential advantages for restoring and maintaining LL in multilevel lumbar fusion, particularly in cases with low BMD.

Risk Factors Affecting Cage Retropulsion into the Spinal Canal Following Posterior Lumbar Interbody Fusion: Association with Diffuse Idiopathic Skeletal Hyperostosis

Study DesignThis was a retrospective observational study.PurposeWe identify risk factors, including physical and surgical factors, and comorbidities affecting cage retropulsion following posterior lumbar interbody fusion (PLIF).Overview of LiteratureDiffuse idiopathic skeletal hyperostosis (DISH) is considered a risk factor for reoperation after PLIF. We evaluated the effect of DISH on cage retropulsion into the spinal canal, which may require surgical revision for severe neurological disorders.MethodsA total of 400 patients (175 men, 225 women) who underwent PLIF were observed for >1 year. Factors investigated included the frequency of cage retropulsion and surgical revision. In addition, physical (age, sex, disease), surgical (fusion and PLIF levels, cage number, grade 2 osteotomy), and comorbid (DISH, existing vertebral fracture) factors were compared between patients with and without cage retropulsion. Factors related to surgical revision during the observation period were also considered.ResultsCage retropulsion occurred in 15 patients and surgical revision was performed in 11. Revisions included the replacement of pedicle screws (PSs) with larger screws in all patients and supplementary implants in 10. Among the patients with cage retropulsion, the average PLIF level was 2.7, with DISH present in nine patients and existing vertebral fractures in six. Factors affecting cage retropulsion were diagnoses of osteoporotic vertebral fracture, multilevel fusion, single-cage insertion, grade 2 osteotomy, presence of DISH, and existing vertebral fracture. Multivariable analysis indicated that retropulsion of a fusion cage occurred significantly more frequently in patients with DISH and multilevel PLIF.ConclusionsDISH and multilevel PLIF were significant risk factors affecting cage retropulsion. Revision surgery for cage retropulsion revealed PS loosening, suggesting that implant replacement was necessary to prevent repeat cage retropulsion after revision.

Risk of adjacent segment disease after 'topping-off' multi-level lumbar fusions with posterior dynamic stabilisers: an observational cohort study.

To determine whether 'topping-off' lumbar fusions, using posterior dynamic stabilising devices (PDSs) with specific biomechanical parameters, reduces the risk of adjacent segment disease (ASD). Survival analysis of two non-randomised cohorts, with or without 'topping-off' (T/O or NoT/O), compared the risk of further surgery for ASD following multi-level posterior lumbar interbody fusion (PLIF). The study sample comprised consecutive patients, aged 55 + years, with degenerative pathology at 2, 3 or 4 levels. The NoT/O cohort underwent surgery between August 1993 and September 2019 (n = 425) and the T/O cohort between September 2011 and September 2019 (n = 146). Comparison of ASD risk between cohorts used Cox proportional hazards (CPH) modelling and Kaplan-Meier survivorship analysis. Analysis was completed on 571 operations across 507 patients. Median follow-up was 63months (range 0.3-196) and 37months (range 1.7-98) for the NoT/O and T/O cohorts, respectively. Of 423 patients, 125 (29.6%) patients in the NoT/O cohort underwent further surgery for ASD and 16/145 (11.03%) in the T/O cohort. The hazard ratio (T/O: NoT/O) from the CPH model was 0.42 (95% CL: 0.24-0.74, P = 0.003). Mean annual incidence across the first 5years was 5.0% in the NoT/O cohort compared with 2.8% in the T/O cohort (P = 0.029). No patient required surgery or developed ASD at a 'topped-off' level. Two patients developed asymptomatic pedicle screw loosening at the level of the PDS device. PROMs were similar between cohorts. This large, non-randomised, observational study found an approximately 60% reduction in further surgery for ASD with the use of the PDS to 'top-off' PLIF fusions. PDS device-related complications were very low.

188. The safety and efficacy of hydrogen peroxide in controlling blood loss and surgical site infection after multi-segmental lumbar spine surgery: a retrospective, case-controlled study of 2,626 patients

BACKGROUND CONTEXT Multiple-level lumbar fusion surgery is associated with prolonged duration of surgery and significant blood loss, which are deemed significant risk factors for postoperative SSI. Controlling the blood loss and improving local resistance to pathogens is extremely valuable to reduce perioperative complications, including SSI, and speed up recovery after surgery. Concerns regarding the safety profile of TXA, whether it increases the incidence of thromboembolic events, such as deep vein thrombosis (DVT), pulmonary embolism (PE), and myocardial infarctions (MI), have been raised frequently, especially for the patients who have accompanying cardiovascular and cerebrovascular diseases, which are relatively common in patients with degenerative spinal disease. Additionally, it is strongly debated whether the usage of vancomycin powder can induce culture-negative seroma formation and affect bone healing. Hydrogen peroxide (H2O2) is an inexpensive and readily available option whose hemostatic and antiseptic properties have been separately confirmed in several previous studies. However, whether H2O2 can integrate the advantages of vancomycin and TXA in controlling blood loss and postoperative SSI simultaneously after lumbar spine surgery has not been explored, neither have its complications. PURPOSE This study aimed to explore the safety and efficacy of H2O2 in controlling blood loss and SSI after multi-segmental lumbar spine surgery. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE A total of 2,626 patients who underwent multi-segmental lumbar spinal surgery between January 2015 and January 2018 were included in this study. According to whether H2O2 irrigation was applied, they were divided into control group (1,345 patients) and experimental group (1,281 patients).The inclusion criteria were: (1) patients were diagnosed with thoracic and/or lumbar degenerative diseases, such as spinal canal stenosis, disc herniation, spondylolisthesis, and/or degenerative scoliosis; (2) patients treated with multilevel (operated level > 2) posterior lumbar interbody fusion (PLIF) with or without posterolateral fusion. The exclusion criteria were: patients diagnosed with spinal fracture-dislocation, infection, tuberculosis, tumor, congenital spinal deformity or received revision surgery; patients with a coagulation or hemoglobin dysfunction before surgery; dura tear accompanied by cerebrospinal fluid leakage detected intraoperatively; the perioperative use of hemostatic agents such as TXA or treatment with antifibrinolytic drugs. OUTCOME MEASURES The primary outcome evaluated was the incidence of SSI. The definition of SSI including superficial and deep infection after lumbar spinal surgery was derived from the guidelines published by the U.S. Centers for Disease Control and Prevention. Superficial infection is defined as occurring within 30 days after surgery, involving only the incision skin and subcutaneous tissue. Deep infection is defined as occurring within 1 year after operation, characterized by superficial infection, the involving fascia and myometrium. Besides the demographic parameters, the laboratory examination results and surgery related information such as operative time, numbers of operated levels, intraoperative blood loss, postoperative drainage, postoperative SSI and extubation time were recorded. The perioperative complications including pneumocephalus, symptomatic DVT, PE and MI were included in the evaluation. METHODS A standard posterior midline incision and exposure was applied; and irrigation with 1 L of saline was performed before skin closure in all patients. For the experimental group, the incision was soaked with 50 mL of 3% H2O2 solution for 30 s before the saline irrigation. RESULTS No significant differences were seen regarding demographic parameters, laboratory examination results, comorbidities and surgical related information. The extubation time and postoperative drain collection were lower in the experimental group (3.6±0.5 days vs 4.1±0.6, p=0.402; 251.8±67.5 vs 291.8±71.3, p=0.013). In the control group, the rate of SSI was 2.4% (32/1345), including 17 superficial wound infections and 15 deep wound infections. In the experimental group, the SSI rate was 1.4% (18/1281), including 15 patients with superficial wound infection and three with deep wound infection. Staphylococcus aureus was the most common organism, especially in the experimental group (66.7% vs 50%). There was no significant difference between both groups in the perioperative complications such as hematencephalon, DVT, PE and MI (p>0.05, respectively). Pneumocephalus was not observed in either group. CONCLUSIONS The application of H2O2 in PLIF does not increase the perioperative complications such as hematencephalon, DVT, PE, MI, and especially pneumocephalus; it also reducing the blood loss and SSI after surgery, which is quite promising for patients with a high risk of thromboembolic events and beneficial for controlling the increasing number of vancomycin-resistant bacteria. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical Outcomes of Multilevel Posterior Lumbar Interbody Fusion versus Lateral Lumbar Interbody Fusion for the Correction of Adult Spinal Deformity: A Comparative Clinical Study

Study DesignA retrospective case control study.PurposeThe purpose of this study was to compare the surgical outcomes of multilevel lateral lumbar interbody fusion (LIF) and multilevel posterior lumbar interbody fusion (PLIF) in the surgical treatment of adult spinal deformity (ASD) and to evaluate the sagittal plane correction by combining LIF with posterior-column osteotomy (PCO).Overview of LiteratureThe surgical outcomes between multilevel LIF and multilevel PLIF in ASD patients remain unclear.MethodsWe retrospectively reviewed 31 ASD patients who underwent multilevel LIF combined with PCO (LIF group, n=14) or multilevel PLIF (PLIF group, n=17) and with a minimum 2-year follow-up. In the comparison between LIF and PLIF groups, their mean age at surgery was 69.4 vs. 61.8 years while the mean follow-up period was 29.2 vs. 59.3 months. We evaluated the transition of pelvic incidence–lumbar lordosis (PI–LL) and disc angle (DA) in the LIF group, in fulcrum backward bending (FBB), after LIF and after posterior spinal fusion (PSF) with PCO. The spinopelvic radiographic parameters were compared between LIF and PLIF groups.ResultsCompared with the PLIF group, the LIF group had less blood loss and comparable surgical outcomes with respect to radiographic data, health-related quality of life scores and surgical time. In the LIF group, the mean DA and PI–LL were unchanged after LIF (DA, 5.8°; PI–LL, 15°) compared with the values using FBB (DA, 4.3°; PI–LL, 15°) and improved significantly after PSF with PCO (DA, 8.1°; PI–LL, 0°).ConclusionsIn the surgical treatment of ASD, multilevel LIF is less invasive than multilevel PLIF and combination of LIF and PCO would be necessary for optimal sagittal correction in patients with rigid deformity.

Retracted: Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders.

We have retracted this publication because we were informed that an image used by the authors was copied from the following article: J Korean Neurosurg Soc. 2011 Nov; 50(5): 441-445. Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System: Technical Tips, Surgical Outcomes (https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3259464/pdf/jkns-50-441.pdf) (https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3259464/). Reference: 1. Xiaoyang Liu, Guangrun Li, Jiefeng Wang, Heqing Zhang: Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders. Med Sci Monit, 2015; 21: 3652-3657. DOI: 10.12659/MSM.894890.

Preemptive analgesia with a single low dose of intrathecal morphine in multilevel posterior lumbar interbody fusion surgery: a double-blind, randomized, controlled trial

Patients undergoing lumbar spinal surgery may experience considerable pain in the early postoperative period, and poor pain control after multilevel lumbar spinal fusion surgery is frequently associated with multiple complications and delayed discharge from hospital. The current study evaluated the efficacy and safety of preemptive analgesia with intrathecal morphine (ITM) in patients undergoing multilevel posterior lumbar spinal fusion surgery. Double-blinded, randomized, controlled trial. Ninety-two patients aged between 18 and 80 years who were scheduled to undergo elective lumbar laminectomy (L3-S1) and dual-level fusions. The primary endpoint was the degree of postoperative pain at rest and during movement evaluated using a 10-point visual analogue scale. The secondary outcomes included the consumption of analgesics, the patient-assessed postoperative and satisfaction scores, adverse effects, time to first ambulation, and length of hospital stay. Patients were randomly allocated to either the ITM group that received 0.2 mg of ITM or the control (CON) group that received 2 ml of 0.9% saline as a skin infiltration 30 minutes prior to anesthesia induction. The ITM group had a significantly lower visual analogue scale score than the CON group during the first 3 days postoperatively (at rest, P=0.000, during movement, P=0.000). The ITM group used significantly less sufentanil than the CON group in the first 3 days postoperatively (p=.000) in patient-controlled intravenous analgesia, as well as in supplemental analgesic demands. The ITM group reported a greater degree of satisfaction with the whole hospitalization experience than the CON group (2.4±0.6 vs. 1.9±0.6, p=.000). The two groups did not significantly differ regarding adverse effects, length of hospital stay, and time taken to regain the ability to walk without support. Preemptive analgesia with ITM results in significantly improved early postoperative pain control and decreased postoperative patient-controlled intravenous analgesia consumption, with no increase in adverse effects.

The clinical and radiological outcomes of multilevel posterior lumbar interbody fusion in the treatment of degenerative scoliosis: a consecutive case series with minimum 2 years follow up.

Surgical treatment for adult degenerative scoliosis (ADS) is a complex undertaking and is associated with a high complication rate. Our aim was to evaluate the clinical and radiological outcomes, mortality and morbidity of multilevel posterior lumbar interbody fusion (MPLIF) in the treatment in ADS based on the experience of a single tertiary referral center for spinal surgery. We performed a retrospective analysis of prospectively collected data of consecutive patients who had undergone multi-level posterior interbody fusion for degenerative scoliosis. We prospectively recorded patients' demographics, co-morbidities; coronal and sagittal plane deformity assessment and surgical details: number of instrumented levels, and intra-operative and postoperative complications. Functional outcomes and patient-reported complications were entered in our local spine surgery database (part of the Eurospine Spine Tango Registry) and used to collect data on functional scores and patient-reported complications preoperatively and at 6, 12 and 24 months' follow-up. Our study involved 13 males and 51 females with a mean age of 70.26 (range 49-90, SD 8.9). MPLIF was performed at five levels in one patient, four levels in 29 patients, three levels in 20 patients, and two levels in 14 patients. There were a total of 14 (21.87%) major, minor and mechanical complications. There were no procedure-related mortalities. The average COMI and Eq5d scores improved significantly post-surgery, and this improvement was maintained at a mean follow-up of up to two years. Multilevel posterior interbody fusion is a safe procedure, and in selected cases can result in good clinical and radiological outcomes with improvement in patient quality of life.

Correction of sagittal plane deformity and predictive factors for a favourable radiological outcome following multilevel posterior lumbar interbody fusion for degenerative scoliosis

Correction of sagittal plane deformity and predictive factors for a favourable radiological outcome following multilevel posterior lumbar interbody fusion for degenerative scoliosis

Correction of sagittal plane deformity and predictive factors for a favourable radiological outcome following multilevel posterior lumbar interbody fusion for mild degenerative scoliosis.

Limited data is available in the literature on the radiographic results of multilevel posterior lumbar interbody fusion (MPLIF) in the treatment of degenerative scoliosis. The objective of our study was to evaluate the segmental and global correction achieved with MPLIF in the treatment of degenerative scoliosis. Between 2009 and 2014, 42 patients underwent correction of degenerative scoliosis with MPLIF. Several radiological parameters were measured pre- and post-operatively by two independent observers. A statistical analysis was performed to assess the inter-observer reliability of the measurements and to determine the degree of segmental correction achieved at each intervertebral disc. Using sagittal vertical axis (SVA) less than 47mm; lumbar lordosis (LL) within 11° of pelvic incidence (PI); and pelvic tilt (PT) no more than 22° as radiological criteria for procedural acceptability, we determined predictive factors for a favourable radiological outcome. Forty-two patients (34 female) were included in our study. The average amount of correction per segment was 6.2°. The overall correction achieved with MPLIF was 16.6°. Twenty-six of the 42 patients (61.9%) had post-operative SVA values less than 47mm. Nineteen of the 42 patients (45.2%) had average post-operative LL within 11° of the PI. Sixteen of the 42 patients (38.1%) had PT less than 22°. Younger age, female gender and a low pre-operative PT were significantly associated with the attainment of a satisfactory sagittal alignment. Our results demonstrate that a satisfactory correction can be achieved in degenerative scoliosis with MPLIF. In addition, our results show that it is significantly more likely to achieve a satisfactory radiological outcome in younger, female patients with low pre-operative PT.

Hybrid Biosynthetic Autograft Extender for Use in Posterior Lumbar Interbody Fusion: Safety and Clinical Effectiveness

Autologous iliac crest bone graft is the preferred option for spinal fusion, but the morbidity associated with bone harvest and the need for graft augmentation in more demanding cases necessitates combining local bone with bone substitutes. The purpose of this study was to document the clinical effectiveness and safety of a novel hybrid biosynthetic scaffold material consisting of poly(D,L-lactide-co-glycolide) (PLGA, 75:25) combined by lyophilization with unmodified high molecular weight hyaluronic acid (10-12% wt:wt) as an extender for a broad range of spinal fusion procedures. We retrospectively evaluated all patients undergoing single- and multi-level posterior lumbar interbody fusion at an academic medical center over a 3-year period. A total of 108 patients underwent 109 procedures (245 individual vertebral levels). Patient-related outcomes included pain measured on a Visual Analog Scale. Radiographic outcomes were assessed at 6 weeks, 3-6 months, and 1 year postoperatively. Radiographic fusion or progression of fusion was documented in 221 of 236 index levels (93.6%) at a mean (±SD) time to fusion of 10.2+4.1 months. Single and multi-level fusions were not associated with significantly different success rates. Mean pain scores (+SD) for all patients improved from 6.8+2.5 at baseline to 3.6+2.9 at approximately 12 months. Improvements in VAS were greatest in patients undergoing one- or two-level fusion, with patients undergoing multi-level fusion demonstrating lesser but still statistically significant improvements. Overall, stable fusion was observed in 64.8% of vertebral levels; partial fusion was demonstrated in 28.8% of vertebral levels. Only 15 of 236 levels (6.4%) were non-fused at final follow-up

Reduction in adjacent-segment degeneration after multilevel posterior lumbar interbody fusion with proximal DIAM implantation.

OBJECT Multilevel long-segment lumbar fusion poses a high risk for future development of adjacent-segment degeneration (ASD). Creating a dynamic transition zone with an interspinous process device (IPD) proximal to the fusion has recently been applied as a method to reduce the occurrence of ASD. The authors report their experience with the Device for Intervertebral Assisted Motion (DIAM) implanted proximal to multilevel posterior lumbar interbody fusion (PLIF) in reducing the development of proximal ASD. METHODS This retrospective study reviewed 91 cases involving patients who underwent 2-level (L4-S1), 3-level (L3-S1), or 4-level (L2-S1) PLIF. In Group A (42 cases), the patients received PLIF only, while in Group B (49 cases), an interspinous process device, a DIAM implant, was put at the adjacent level proximal to the PLIF construct. Bone resection at the uppermost segment of the PLIF was equally limited in the 2 groups, with preservation of the upper portion of the spinous process/lamina and the attached supraspinous ligament. Outcome measures included a visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI) for functional impairment. Anteroposterior and lateral flexion/extension radiographs were used to evaluate the fusion status, presence and patterns of ASD, and mobility of the DIAM-implanted segment. RESULTS Solid interbody fusion without implant failure was observed in all cases. Radiographic ASD occurred in 20 (48%) of Group A cases and 3 (6%) of Group B cases (p < 0.001). Among the patients in whom ASD was identified, 9 in Group A and 3 in Group B were symptomatic; of these patients, 3 in Group A and 1 in Group B underwent a second surgery for severe symptomatic ASD. At 24 months after surgery, Group A patients fared worse than Group B, showing higher mean VAS and ODI scores due to symptoms related to ASD. At the final follow-up evaluations, as reoperations had been performed to treat symptomatic ASD in some patients, significant differences no longer existed between the 2 groups. In Group B, flexion/extension mobility at the DIAM-implanted segment was maintained in 35 patients and restricted or lost in 14 patients, 5 of whom had already lost segmental flexion/extension mobility before surgery. No patient in Group B developed ASD at the segment proximal to the DIAM implant. CONCLUSIONS Providing a dynamic transition zone with a DIAM implant placed immediately proximal to a multilevel PLIF construct was associated with a significant reduction in the occurrence of radiographic ASD, compared with PLIF alone. Given the relatively old age and more advanced degeneration in patients undergoing multilevel PLIF, this strategy appears to be effective in lowering the risk of clinical ASD and a second surgery subsequent to PLIF.

Risk Factors for Cage Retropulsion After Posterior Lumbar Interbody Fusion

Single-center retrospective study. We examined the risk factors for cage retropulsion after posterior lumbar interbody fusion (PLIF) performed for patients with degenerative lumbar spinal diseases. Although PLIF is a widely accepted procedure, problems remain regarding perioperative and postoperative complications. There are few reported studies identifying specific risk factors for cage retropulsion, one of the implant-related complications after PLIF, although several case reports have been published. Between April 2006 and July 2010, 1070 patients with various degenerative lumbar spinal diseases underwent single- or multilevel PLIF combined with posterolateral fusion, using posterior pedicle screw fixation and box-type cages. Their medical records and preoperative radiographs were reviewed and the factors influencing the incidence of cage retropulsion were analyzed. There were 9 cases of cage retropulsion (7 men and 2 women; mean age, 68.2 yr), and it developed within 2 months after surgery in all cases. Five patients had low back pain or leg pain, 3 of whom required revision surgery. The mean fusion level was 3.9 (range, 2-5); in 6 of the 9 patients, the cage had migrated at L5/S, 2 at L4/5, and 1 at L3/4. All of the cages were inserted at the end disc level of multilevel fusion procedures. The disc heights and ranges of motion were significantly greater in patients with cage retropulsion, and patients with a pear-shaped disc space also showed a higher rate of cage retropulsion. These results indicate that PLIF at L5/S, a wide disc space with instability, multilevel fusion surgery, and a pear-shaped disc space on lateral radiographs are risk factors for cage retropulsion. The identification of these risk factors should allow us to avoid this complication, and the use of expandable cages is an effective option for such cases.

Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System : Technical Tips, Surgical Outcomes

There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy. Forty-two patients who underwent mini-open PLIF using the percutaneous screw fixation system were studied. The mean age of the patients was 59.1 (range, 23 to 78 years). Two levels were involved in 32 cases and three levels in 10 cases. The clinical outcome was assessed using the visual analog scale (VAS) and Low Back Outcome Score (LBOS). Achievement of radiological fusion, intra-operative blood loss, the midline surgical scar and procedure related complications were also analyzed. The mean follow-up period was 25.3 months. The mean LBOS prior to surgery was 34.5, which was improved to 49.1 at the final follow up. The mean pain score (VAS) prior to surgery was 7.5 and it was decreased to 2.9 at the last follow up. The mean estimated blood loss was 238 mL (140-350) for the two level procedures and 387 mL (278-458) for three levels. The midline surgical scar was 6.27 cm for two levels and 8.25 cm for three level procedures. Complications included two cases of asymptomatic medial penetration of the pedicle border. However, there were no signs of neurological deterioration or fusion failure. Multi-level, minimally invasive PLIF can be performed effectively using the percutaneous transpedicular screw fixation system. It can be an alternative to the traditional open procedures.

One-stage three-dimensional correction and fusion: a multilevel posterior lumbar interbody fusion procedure for degenerative lumbar kyphoscoliosis. Technical note.

Surgery for degenerative lumbar kyphoscoliosis (DLKS) is very challenging because the curve has become rigid due to circumferential osteoarthritic changes. Therefore, a standard procedure involving correction and fusion after decompression of the nerves has not yet been established. The authors have been searching for an effective procedure that provides adequate decompression and three-dimensional (3D) correction for symptomatic DLKS. In this report they describe a new 3D correction and fusion technique involving multilevel posterior lumbar interbody fusion. They analyze the results obtained in the first 23 cases and discuss the advantages and disadvantages of the procedure. The correction effect was excellent, and compared with other instrumentation-assisted procedures, this surgery is not remarkably invasive. Although the procedure is limited in achieving normal sagittal alignment and the acceleration rate of adjacent-disc degeneration remains relatively high, it is an option for the rigid deformity characterized by DLKS.

Novel bioabsorbable interbody fusion spacer–assisted fusion for correction of spinal deformity

The authors report the cases of 12 patients with medically refractory mechanical low-back pain and intermittent radicular symptoms in whom radiography demonstrated evidence of multilevel lumbosacral degenerative kyphotic and scoliotic deformity and spondylolisthesis. These patients underwent multilevel posterior lumbar interbody fusion in which Macropore bioabsorbable spacers were placed. Each patient underwent at least 1 year of clinical and radiographic follow up. This series illustrates the novel use of bioabsorbable interbody spacers and fusion technique for correction of spinal deformity due to advanced degenerative kyphoscoliosis and spondylolisthesis.