Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?

Introduction

Both anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) surgeries are performed to obtain a solid fusion to treat lumbar spondylosis. This systematic review investigated whether surgical complications, nonfusion rate, radiographic outcome, and clinical outcome of ALIF were significantly different from those of TLIF.

Method

A computerized search of the electronic databases MEDLINE was conducted. Only therapeutic studies with a prospective or retrospective comparative design were considered for inclusion in the present investigation. Two reviewers independently extracted relevant data from each included study. Statistical comparisons were made when appropriate.

Results

Nine studies were determined to be appropriate for the systematic review, and all studies were retrospective comparative studies. Blood loss and operative time in ALIF was greater than in TLIF. There was no significant difference in the complication rate between ALIF and TLIF. The restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF was superior to TLIF. However, clinical outcomes in ALIF were similar with TLIF, and there was no significant difference in nonfusion rate between the two techniques. Costs of ALIF were greater than those of TLIF.

Conclusion

Clinical outcomes and nonfusion rate in ALIF were similar to TLIF. However, the restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF were superior to those in TLIF, while blood loss, operative time, and costs in ALIF were greater than in TLIF.     

Cervical adjacent segment pathology following fusion: Is it due to fusion?

Adjacent segment pathology affects 25% of patients within ten years of anterior cervical diskectomy and fusion (ACDF). Laboratory studies demonstrate fused segments increase adjacent level stress including elevated intradiscal pressure and increased range of motion. Radiographic adjacent segment pathology (RASP) has been associated to ACDF in multiple statistically significant studies. Randomized controlled trials (RCTs) comparing anterior cervical discectomy and arthroplasty (ACDA) and ACDF have confirmed ACDF accelerates RASP. The question of greatest clinical interest is whether ACDA, artificial disc surgery, results in fewer adjacent level surgeries than ACDF. Current RCT follow up results reveal only non statistically significant trends favoring ACDA yet the post operative periods are only two to four years. Statistically significant increased RASP in ACDF patients however is already documented. The RCT patients’ average ages are in the mid forties with an expected longevity of up to forty more years. Early statistically significant increased RASP in the ACDF patients supports our prediction that given sufficient follow up of ten or more years, fusion will lead to statistically significant higher rate of adjacent level surgery compared to artificial disc surgery.     

Discectomy combined with isolated facet joint fusion—as an alternative fusion technique. Our clinical experience

Objective  The purpose of the present study is to present our experience and clinical results with surgical technique of discectomy and facet joint fusion. Our goal was to achieve pain free and stable back (segmental stability) after lumbar disc surgery and to assess the status of fusion and its relationship with clinical results. Study design  The proposed study is a prospective clinical study of low back pain/leg pain due to prolapse intervertebral disc treated with discectomy with facet joint fusion (using titanium screws) A case of symptomatic disc prolapse not improving on at least 6 weeks of conservative management. Clinical and radiological follow up was done up to average of five years. Method  After laminectomy and disc removal. Denude the facet joint cartilage with help of fine curved curette and fine slivers of bone graft taken from spinous processes are impacted into facet joint space after distracting them with help of spreader. Titanium partially threaded cancellous screws with 2.7 mm drill bit without taping. Results  Complete fusion across bilateral facets was achieved in 56.2% levels. Partial fusion was achieved in 34.3% levels. No fusion at all was seen in only 3 levels (9.3%). On applying chi square test between the 4 groups, chi square value came to be 44.92 with P value of <0.001. This implied that Post-op Oswestry score and clinical results have statistically significant association with status of fusion Conclusion  This study demonstrates that facet screw fixation has multiple advantages. The technique is not only easy to implement by placing a small screw through a facet joint without any excessive retraction of neural structures and any distraction of posterior elements thus preserving the segmental stability. It produces excellent clinical results that are comparable to other exhaustive surgical procedures and more bulky spinal instrumentation systems     

Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5-5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.     

Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5–5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.     

Circumferential fusion: a comparative analysis between anterior lumbar interbody fusion with posterior pedicle screw fixation and transforaminal lumbar interbody fusion for L5–S1 isthmic spondylolisthesis

Background Context

Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5–S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques.

Effect of posterolateral fusion on thoracolumbar burs fractures

OBJECTIVE: To evaluate the efficacy and significance of posterolateral fusion in preventing failure of short-segment stabilization for the treatment of thoracolumbar burst fractures. METHODS: Sixty patients with thoracolumbar burst fractures were included in the study. The patients were classified into two groups (n equal to 30 in each group). In Group A, patients were treated in our hospital with short-segment instrumentation via posterolateral fusion with iliac bone. In Group B, patients were treated in other hospital with short-segment fixation without fusion. All cases came to our hospital for reexamination. There were 18 males and 12 females in Group A with a mean age of 42.3 years (range, 24 to 52 years) and 16 males and 14 females in Group B with a mean age of 41.5 years (range, 19 to 54 years). Radiographic (Cobb angle, kyphosis of the vertebral body, and sagittal index) and clinical outcomes (Low Back Outcome Score ) were analyzed after an average follow-up of 16 months. RESULTS: After operation, Cobb angle was reduced from 19.3 degrees to 3.1 degrees in Group A and from 19.1 degrees to 3.3 degrees in Group B (P>0.05). It was 5.9 degrees in Group A and 11. 9 degrees in Group B at the final follow-up (P<0.01). Its average loss of correction was 2.8 degree in Group A and 8.6 degrees in Group B. Average kyphosis of the vertebral body was reduced from 21.3 degrees to 6.2 degrees in Group A and from 21.7 degrees to 7.4 degrees in Group B (P>0.05). It was decreased to 7.9 degrees in Group A and 13.5 degrees in Group B at the final follow-up (P<0.01). Its average loss of correction was 1.7 degrees in Group A and 6.1 degrees in Group B. Sagittal index was reduced from 21.3 degrees to 3.6 degrees in Group A and from 20.5 degrees to 3.8 degrees in Group B (P<0.05). It was decreased to 5.1 degrees in Group A and 9.8 degrees in Group B at the final follow-up (P<0.01). Its average loss was 1.5 degrees in Group A and 6.0 degrees in Group B. In Group A, 73.3% of patients had an excellent result based on Low Back Outcome Score system, while that in Group B was only 43.3%. CONCLUSIONS: Posterolateral fusion is an effective measure to prevent implant failure, and decrease loss of correction, posttraumatic kyphosis and neurological deficit during the treatment of thoracolumbar burst fractures. Short-segment fixation of thoracolumbar burst fractures without fusion obviously increases failure rate and it is not an optional procedure.     

Should smoking habit dictate the fusion technique?

The aim of this study was to evaluate the influence of smoking on the outcome of patients undergoing surgery for degenerative spinal diseases, and to examine whether smoking had a differential impact on outcome, depending on the fusion technique used. The cohort included 120 patients treated with two different fusion techniques (translaminar screw fixation and TLIF). They were categorised with regard to their smoking habits at the time of surgery and completed the Core Outcome Measures Index at baseline and follow-up (FU) (3, 12 and 24 months FU); at FU they also rated the global outcome of surgery. The distribution of smokers was comparable in the two groups. For the TS group, the greater the number of cigarettes smoked, the less the reduction in pain intensity from pre-op to 24 months FU; the relationship was not significant for the TLIF group. The percentage of good global outcomes declined with time in the TS smokers such that by 24 months FU, there was a significant difference between TS smokers and TS-non-smokers. No such difference between smokers and non-smokers was evident in the TLIF group at any FU time. In conclusion, the TS technique was more vulnerable to the effects of smoking than was TLIF: possibly the more extensive stabilisation of the 360° fusion renders the environment less susceptible to the detrimental effects on bony fusion of cigarette smoking.     

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.     

Does fusion status after posterior lumbar interbody fusion affect patient-based QOL outcomes? An evaluation performed using a patient-based outcome measure

Background Although delayed union or pseudoarthrosis after lumbar arthrodesis has been recognized as a major radiographic complication, little has been known about the effect of fusion status on the patient’s quality-of-life (QOL) outcome. The purpose of this study was to investigate the effects of fusion status after posterior lumbar interbody fusion (PLIF) on QOL outcomes by using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).Methods Among 100 patients who underwent single level PLIF for spinal canal stenosis, 29 who had not achieved fusion (incomplete fusion group) and 29 age- and sex ratio-matched patients who had achieved fusion (fusion group) 6 months after surgery were enrolled. Overall clinical evaluation was performed before and 6 months after surgery: the physician determined the Japanese Orthopaedic Association Score for Low Back Pain (JOA score); the JOABPEQ and visual analogue scale (VAS) values were collected. The recovery rate of the JOA score, changes in all JOABPEQ subdomain scores and in the VAS values were calculated. All variables were compared between the groups.Results The preoperative JOA scores, JOABPEQ scores of all subdomains, and VAS values of all categories did not differ between the groups. The recovery rate was higher in the fusion group than the incomplete fusion group (p = 0.0185). The changes in the JOABPEQ scores for walking ability and social life function were significantly greater in the fusion group than the incomplete fusion group (walking ability, p = 0.0172; social life function, p = 0.0191). The postoperative VAS values and changes in the VAS values for all categories did not differ between the groups.Conclusions Incomplete fusion after PLIF correlated with poor improvement in walking ability and social life function. Therefore, the achievement of fusion after PLIF is essential to obtain better patient QOL outcomes.     

Can autologous bone culture predict spinal fusion capacity?

The capacity of the individual patient to initiate osteoblast proliferation as a predictor for successful lumbar spinal fusion has not yet been reported. The objectives of this study were, first, to analyze the relationship between in vitro osteoblast proliferation and clinical bony fusion in the individual patient in order to predict the fusion outcome and, second, to measure the effect of preoperative tobacco smoking on osteoblast proliferation. Sixty-one patients (mean age 46 years) underwent posterolateral lumbar fusion in the period 1994–1995. Thirty-eight patients received CD pedicle screw implants and 23 received posterolateral fusions alone. During surgery, autogenous iliac bone was harvested and 1 g of trabecular bone without blood or bone marrow was then isolated for cell culturing. The cultures were classified as excellent (confluence within 4 weeks), good (confluence between 4 and 6 weeks) and poor (no or poor growth). Spine fusion was evaluated by two independent observers from plain anterior-posterior, lateral, and flexion/extension radiographs taken 1 year postoperatively, and the functional outcome was measured by the Dallas Pain Questionnaire (DPQ). Twenty-three patients had excellent, 19 good, and 19 poor in vitro osteoblast proliferation. Bony fusion was obtained in 77% of patients: 83% in the CD instrumentation group and 70% in the non-instrumentation group (NS). There was no significant correlation between osteoblast proliferation and spinal fusion or functional outcomes when analyzing the CD instrumentation and non-instrumentation groups together or separately. Elderly patients had a significantly poorer osteoblast proliferation than younger patients (P < 0.008). Preoperative tobacco consumption had no discernible effect on osteoblast proliferation, and no correlation between smoking and fusion was found. Further refinement of autologous osteoblast culturing may provide a biological tool for selection of patients who require biological enhancement of their bone fusion capacity. The poorer osteoblast proliferation related to advanced age supports the important negative biological influence of age on bony fusion. However, with more sensitive testing and better discrimination, other results are possible – or can in any event not be excluded. Received: 17 April 1998 Revised: 10 September 1998 Accepted: 12 October 1998