Dataset Information

Interbody Fusions in the Lumbar Spine: A Review.

ABSTRACT:

Background

Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height.

Questions/purposes

We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine.

Methods

Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review.

Results

Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK-titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation.

Conclusions

All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.

SUBMITTER: Verma R

PROVIDER: S-EPMC7253570 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundTransforaminal lumbar interbody fusion (TLIF) is an effective surgery for lumbar degenerative disease. However, this fusion technique requires resection of inferior facet joint to provide access for superior facet joint resection, which results in reduced lumbar spinal stability and unnecessary trauma. We have previously developed extraforaminal lumbar interbody fusion (ELIF) that can avoid back muscle injury with direct nerve root decompression. This study aims to show that ELIF enhances lumbar spinal stability in comparison to TLIF by comparing lumbar spinal stability of L4-L5 range of motion (ROM) on 12 cadaveric spine specimens after performing TLIF or ELIF.Methods12 cadaveric spine specimens were randomly divided and treated in accordance with the different internal fixations, including ELIF with a unilateral pedicle screw (ELIF+UPS), TLIF with a unilateral pedicle screw (TLIF+UPS), TLIF with a bilateral pedicle screw (TLIF+BPS), ELIF with a unilateral pedicle screw and translaminar facet screw (ELIF+UPS+TLFS) and ELIF with a bilateral pedicle screw (ELIF+BPS). The treatment groups were exposed to a 400-N load and 6 N·m movement force to calculate the angular displacement of L4-L5 during anterior flexion, posterior extension, lateral flexion and rotation operation conditions.ResultsThe ROM in ELIF+UPS group was smaller than that of TLIF+UPS group under all operating conditions, with the significant differences in left lateral flexion and right rotation by 36.15% and 25.97% respectively. The ROM in ELIF+UPS group was higher than that in TLIF+BPS group. The ROM in the ELIF+UPS+TLFS group was much smaller than that in the ELIF+UPS group, but was not significantly different than that in the TLIF+BPS group.ConclusionsDespite that TLIF+BPS has great stability, which can be comparable by that of ELIF+UPS. Additionally, ELIF stability can be further improved by using translaminar facet screws without causing more tissue damage to patient.

Project description:Background:Comparison of single-level open and minimally invasive transforaminal lumbar interbody fusions (O-TLIF and MI-TLIF) of a single surgeon and presentation of his MI-TLIF learning curve in a retrospective observational cohort study. Methods:27 MI-TLIF and 31 O-TLIF patients, performed between 03/01/2013 and 03/31/2018, were compared regarding the operative time, blood loss, blood transfusion frequency, postoperative length of stay (LOS), and adverse events. An overall comparison of pre- and postoperative Oswestry Disability Index (ODI) results and Visual Analog Score (VAS) results of low back and leg pain was performed in the case of the two techniques. For a learning curve presentation, the MI-TLIF cases were compared and the optimal operative time was determined. Results:The gender ratio and age did not differ in the groups. Operative time showed no difference (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (p=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (P=0.88) between the MI-TLIF (161.2?±?33.7 minutes) and O-TLIF groups (160?±?33.6 minutes). Intraoperative blood loss was less (. Conclusions:Similar operative time and postoperative quality of life improvement can be achieved by MI-TLIF procedure as with O-TLIF, and additionally LOS and blood loss can be reduced. When comparing parameters, MI-TLIF can be an alternative option for O-TLIF with a similar complication profile. The learning curve of MI-TLIF can be steep, although it depends on the circumstances.

Project description:IntroductionThe demand for spinal fusion surgery has increased over the last decades. Health care providers should take costs and cost-effectiveness of these surgeries into account. Open transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are two widely used techniques for spinal fusion. Earlier research revealed that TLIF is associated with less blood loss, shorter surgical time and sometimes shorter length of hospital stay, while effectiveness of both techniques on back and/or leg pain are equal. Therefore, TLIF could result in lower costs and be more cost-effective than PLIF. This is the first systematic review comparing direct and indirect (partial) economic evaluations of TLIF with PLIF in adults with lumbar spondylolisthesis. Furthermore, methodological quality of included studies was assessed.MethodsSearches were conducted in eight databases for reporting on eligibility criteria; TLIF or PLIF, lumbar spondylolisthesis or lumbar instability, and cost. Costs were converted to United States Dollars with reference year 2020. Study quality was assessed using the bias assessment tool of the Cochrane Handbook for Systematic Reviews of Interventions, the Level of Evidence guidelines of the Oxford Centre for Evidence-based Medicine and the Consensus Health Economic Criteria (CHEC) list.ResultsOf a total of 693 studies, 16 studies were included. Comparison of TLIF and PLIF could only be made indirectly, since no study compared TLIF and PLIF directly. There was a large heterogeneity in health care and societal perspective costs due to different in-, and exclusion criteria, baseline characteristics and the use of costs or charges in calculations. Health care perspective costs, calculated with hospital costs, ranged from $15,867-$43,217 in TLIF-studies and $32,662 in one PLIF-study. Calculated with hospital charges, it ranged from $8,964-$51,469 in TLIF-studies and $21,838-$93,609 in two PLIF-studies. Societal perspective costs and cost-effectiveness, only mentioned in TLIF-studies, ranged from $5,702/QALY-$48,538/QALY and $50,092/QALY-$90,977/QALY, respectively. Overall quality of studies was low.ConclusionsThis systematic review shows that TLIF and PLIF are expensive techniques. Moreover, firm conclusions about the preferable technique, based on (partial) economic evaluations, cannot be drawn due to limited studies and heterogeneity. Randomized prospective trials and full economical evaluations with direct TLIF and PLIF comparison are needed to obtain high levels of evidence. Furthermore, development of guidelines to perform adequate economic evaluations, specified for the field of interest, will be useful to minimize heterogeneity and maximize transferability of results.Trial registrationProspero-database registration number: CRD42020196869.