The impact of adding posterior instrumentation to transpsoas lateral fusion: a systematic review and meta-analysis

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Transpsoas lateral interbody fusion is one of the lateral minimally invasive approaches for lumbar spine surgery. Most surgeons insert the interbody cage laterally and then insert pedicle or cortical screw and rod instrumentation posteriorly. However, standalone cages have also been used to avoid posterior instrumentation. To the best of the authors’ knowledge, the literature on comparison of the two approaches is sparse.


The authors performed a systematic review and meta-analysis of the available literature on transpsoas lateral interbody fusion by an electronic search of the PubMed, EMBASE, and Scopus databases using PRISMA guidelines. They compared patients undergoing transpsoas standalone fusion (TP) with those undergoing transpsoas fusion with posterior instrumentation (TPP).


A total of 28 studies with 1462 patients were included. Three hundred and seventy-four patients underwent TPP, and 956 patients underwent TP. The mean patient age ranged from 45.7 to 68 years in the TP group, and 50 to 67.7 years in the TPP group. The incidence of reoperation was found to be higher for TP (0.08, 95% confidence interval [CI] 0.04–0.11) compared to TPP (0.03, 95% CI 0.01–0.06; p = 0.057). Similarly, the incidence of cage movement was found to be greater in TP (0.18, 95% CI 0.10–0.26) compared to TPP (0.03, 95% CI 0.00–0.05; p < 0.001). Oswestry Disability Index (ODI) and visual analog scale (VAS) scores and postoperative transient deficits were found to be comparable between the two groups.


These results appear to suggest that addition of posterior instrumentation to transpsoas fusion is associated with decreased reoperations and cage movements. The results of previous systematic reviews and meta-analyses should be reevaluated in light of these results, which seem to suggest that higher reoperation and subsidence rates may be due to the use of the standalone technique.

ABBREVIATIONS GRADE = Grading of Recommendations Assessment, Development and Evaluation; ODI = Oswestry Disability Index; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; TP = standalone transpsoas lateral lumbar interbody fusion; TPP = transpsoas lateral lumbar interbody fusion with posterior instrumentation; VAS = visual analog scale.

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Article Information

Correspondence Mohamad Bydon: Mayo Clinic, Rochester, MN.

INCLUDE WHEN CITING Published online November 2, 2018; DOI: 10.3171/2018.7.SPINE18385.

M.A.A. and R.A. share first authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Flow diagram depicting the literature review, search strategy, and selection process.

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    Forest plot of reoperations for TP and TPP groups. ES = effect size. Figure is available in color online only.

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    Forest plot of cage movement for TP and TPP groups. Figure is available in color online only.

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    Forest plot of fusion rates for TP and TPP groups. Figure is available in color online only.

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    Forest plot of transient deficits for TP and TPP groups. Figure is available in color online only.



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