The impact of interbody approach and lumbar level on segmental,adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery |
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| Institution: | 1. Department of Neurosurgery, Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, 1100 Ninth Ave. Seattle, WA 98101, USA;2. Department of Health Systems and Population Health, School of Medicine, University of Washington, Seattle, 1959 NE Pacific St, Seattle, WA 98195, USA;3. Department of Neurosurgery, University of California Los Angeles, Westlake Village, 300 Stein Plaza Driveway suite 420, Los Angeles, CA 91361, USA;4. Department of Orthopaedic Surgery, OrthoSouth, Memphis, 6286 Briarcrest Ave. Memphis, TN, 38119, USA;1. McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada;2. Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada;1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA;2. Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA;3. Mechanical Engineering and Electrical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA;1. Department of Neurosurgery, Center for Spine Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA;2. Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA;3. Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA;4. Center for Medical Art and Photography, Cleveland Clinic Foundation, Cleveland, OH, USA;5. Department of Neurosurgery, Hospitals of the University of Pennsylvania, Philadelphia, PA, USA;6. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, OH, USA |
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| Abstract: | BACKGROUND CONTEXTInterbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals.PURPOSEThe purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery.STUDY DESIGNRetrospective cohort.PATIENT SAMPLEThis retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology.OUTCOMES MEASURESMeasurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1.METHODSDue to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened.RESULTS474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients’ alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients’ alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position.CONCLUSIONIn this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level. |
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