Graft subsidence as a predictor of revision surgery following stand-alone lateral lumbar interbody fusion

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OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF.

METHODS

A retrospective review of prospectively collected data was conducted on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria, and compared between those who required revision surgery and those who did not. Additional variables recorded included levels fused, DEXA (dual-energy x-ray absorptiometry) T-score, body mass index, and routine demographic information. The data were analyzed using the Student t-test, chi-square analysis, and logistic regression analysis to identify potential confounding factors.

RESULTS

Of 297 patients, 34 (11.4%) had radiographic evidence of subsidence and 18 (6.1%) required revision surgery. The median subsidence grade for patients requiring revision surgery was 2.5, compared with 1 for those who did not. Chi-square analysis revealed a significantly higher incidence of revision surgery in patients with high-grade subsidence compared with those with low-grade subsidence. Seven of 18 patients (38.9%) requiring revision surgery suffered a vertebral body fracture. High-grade subsidence was a significant predictor of the need for revision surgery (p < 0.05; OR 12, 95% CI 1.29–13.6), whereas age, body mass index, T-score, and number of levels fused were not. This relationship remained significant despite adjustment for the other variables (OR 14.4; 95% CI 1.30–15.9).

CONCLUSIONS

In this series, more than half of the patients who developed graft subsidence following stand-alone LLIF required revision surgery. When evaluating patients for LLIF, supplemental instrumentation should be considered during the index surgery in patients with a significant risk of graft subsidence.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; BMD = bone mineral density; BMI = body mass index; DEXA = dual-energy x-ray absorptiometry; LLIF = lateral lumbar interbody fusion; PLIF = posterior lumbar interbody fusion; TLIF = transforaminal lumbar interbody fusion.

Article Information

Correspondence Adam S. Kanter, Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Ste. B400, Pittsburgh, PA 15213. email: kanteras@upmc.edu.

INCLUDE WHEN CITING Published online November 10, 2017; DOI: 10.3171/2017.5.SPINE16427.

Disclosures Drs. Kanter and Okonkwo receive royalties from Biomet.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graph showing distribution of subsidence grade in patients with subsidence who required revision surgery and those who did not require revision surgery. Values on the y-axis represent the number of patients. Figure is available in color online only.

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    Images obtained in a 68-year-old woman who presented with radiculopathy and back pain. A: Preoperative MRI sequence demonstrates degenerative disc disease and retrolisthesis of L-3 on L-4. B: Intraoperative fluoroscopy reveals an appropriately sized LLIF graft at L3–4; however, there was concern for endplate violation intraoperatively. C: Sagittal CT scan performed 16 weeks postoperatively demonstrates high-grade subsidence. D and E: Postoperative radiographs obtained following revision surgery consisting of open decompression and pedicle screw fixation at L3–4.

  • View in gallery

    Images obtained in a 61-year-old woman who presented with severe progressive back and bilateral lower-extremity pain. A: Preoperative MRI sequence reveals Grade I spondylolisthesis with moderate stenosis at L4–5. B: Intraoperative fluoroscopy demonstrates appropriate graft placement without obvious endplate violation. C: Postoperative CT imaging reveals good positioning of stand-alone interbody graft within the L4–5 disc space without evidence of endplate violation or graft subsidence. D: Delayed CT imaging reveals fracture of the L-5 vertebrae with associated graft subsidence. E: Postoperative radiograph obtained following posterior decompression and pedicle screw and rod placement from L-4 to S-1.

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