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Abhijeet Kadam, Nathan Wigner, Philip Saville and Vincent Arlet

OBJECTIVE

The authors’ aim in this study was to evaluate whether sagittal plane correction can be obtained from the front by overpowering previous posterior instrumentation and/or fusion with hyperlordotic anterior lumbar interbody fusion (ALIF) cages in patients undergoing revision surgery for degenerative spinal conditions and/or spinal deformities.

METHODS

The authors report their experience with the application of hyperlordotic cages at 36 lumbar levels for ALIFs in a series of 20 patients who underwent revision spinal surgery at a single institution. Included patients underwent staged front-back procedures: ALIFs with hyperlordotic cages (12°, 20°, and 30°) followed by removal of posterior instrumentation and reinstrumentation from the back. Patients were divided into the following 2 groups depending on the extent of posterior instrumentation and fusion during the second stage: long constructs (≥ 6 levels with extension into thoracic spine and/or pelvis) and short constructs (< 6 levels). Preoperative and postoperative standing radiographs were evaluated to measure segmental lordosis (SL) along with standard sagittal parameters. Radiographic signs of pseudarthrosis at previously fused levels were also sought in all patients.

RESULTS

The average patient age was 54 years (range 30–66 years). The mean follow-up was 11.5 months (range 5–26 months). The mean SL achieved with 12°, 20°, and 30° cages was 13.1°, 19°, and 22.4°, respectively. The increase in postoperative SL at the respective surgically treated levels for 12°, 20°, and 30° cages that were used to overpower posterior instrumentation/fusion averaged 6.1° (p < 0.05), 12.5° (p < 0.05), and 17.7° (p < 0.05), respectively. No statistically significant difference was found in SL correction at levels in patients who had pseudarthrosis (n = 18) versus those who did not (n = 18). The mean overall lumbar lordosis increased from 44.3° to 59.8° (p < 0.05). In the long-construct group, the mean improvement in sagittal vertical axis was 85.5 mm (range 19–249.3 mm, p < 0.05). Endplate impaction/collapse was noted in 3 of 36 levels (8.3%). The anterior complication rate was 13.3%. No neurological complications or vascular injuries were observed.

CONCLUSIONS

ALIF in which hyperlordotic cages are used to overpower posterior spinal instrumentation and fusion can be expected to produce an increase in SL of a magnitude that is roughly half of the in-built cage lordotic angle. This technique may be particularly suited for lordosis correction from the front at lumbar levels that have pseudarthrosis from the previous posterior spinal fusion. Meticulous selection of levels for ALIF is crucial for safely and effectively performing this technique.

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Philip A. Saville, Abhijeet B. Kadam, Harvey E. Smith and Vincent Arlet

OBJECTIVE

The aim of this study was to evaluate the segmental correction obtained from 20° and 30° hyperlordotic cages (HLCs) used for anterior lumbar interbody fusion in staged anterior and posterior fusion in adults with degenerative spinal pathology and/or spinal deformities.

METHODS

The authors report a retrospective case series of 69 HLCs in 41 patients with adult degenerative spine disease and/or deformities who underwent staged anterior, followed by posterior, instrumentation and fusion. There were 29 females and 12 males with a mean age of 55 years (range 23–76 years). The average follow-up was 10 months (range 2–28 months). Radiographic measurements of segmental lordosis and standard sagittal parameters were obtained on pre- and postoperative radiographs. Implant subsidence was measured at the final postoperative follow-up.

RESULTS

For 30° HLCs, the mean segmental lordosis achieved was 29° (range 26°–34°), but in the presence of spondylolisthesis this was reduced to 19° (range 12°–21°) (p < 0.01). For 20° HLCs, the mean segmental lordosis achieved was 19° (range 16°–22°). The overall mean lumbar lordosis increased from 39° to 59° (p < 0.01). The mean sagittal vertical axis (SVA) reduced from 113 mm (range 38–320 mm) to 43 mm (range −13 to 112 mm). Six cages (9%) displayed a loss of segmental lordosis during follow-up. The mean loss of segmental lordosis was 4.5° (range 3°–10°). A total complication rate of 20% with a 4.1% transient neurological complication rate was observed. The mean blood loss per patient was 240 ml (range 50–900 ml).

CONCLUSIONS

HLCs provide a reliable and stable degree of segmental lordosis correction. A 30° HLC will produce correction of a similar magnitude to a pedicle subtraction osteotomy, but with a lower complication rate and less blood loss.