Risk factors of instrumentation failure and pseudarthrosis after stand-alone L5–S1 anterior lumbar interbody fusion: a retrospective cohort study

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OBJECTIVE

L5–S1 stand-alone anterior lumbar interbody fusion (ALIF) is a reliable technique to treat symptomatic degenerative disc disease but remains controversial for treatment of isthmic spondylolisthesis. In the present study the authors aimed to identify risk factors of instrumentation failure and pseudarthrosis after stand-alone L5–S1 ALIF and to evaluate whether instrumentation failure influenced the rate of fusion.

METHODS

The study included 64 patients (22 [34.4%] male and 42 [65.6%] female, mean age 46.4 years [range 21–65 years]) undergoing stand-alone L5–S1 ALIF using radiolucent anterior cages with Vertebridge plating fixation in each vertebral endplate. Clinical and radiographic data were reviewed, including age, sex, pelvic parameters, segmental sagittal angle (SSA), C7/sacro-femoral distance (SFD) ratio, C7 sagittal tilt, lumbar lordosis (LL), segmental LL, percentage of L5 slippage, L5–S1 disc angle, and posterior disc height ratio. Univariate and multivariate analyses were used to identify risk factors of instrumentation failure and pseudarthrosis.

RESULTS

At a mean follow-up of 15.9 months (range 6.6–27.4 months), fusion had occurred in 57 patients (89.1%). Instrumentation failure was found in 12 patients (18.8%) and pseudarthrosis in 7 patients (10.9%). The following parameters influenced the occurrence of instrumentation failure: presence of isthmic spondylolisthesis (p < 0.001), spondylolisthesis grade (p < 0.001), use of an iliac crest bone autograft (p = 0.04), cage height (p = 0.03), pelvic incidence (PI) (p < 0.001), sacral slope (SS) (p < 0.001), SSA (p = 0.003), and LL (p < 0.001). Instrumentation failure was statistically linked to the occurrence of L5–S1 pseudarthrosis (p < 0.001). On multivariate analysis, no risk factors were found.

CONCLUSIONS

L5–S1 isthmic spondylolisthesis and high PI seem to be risk factors for instrumentation failure in case of stand-alone L5–S1 ALIF, findings that support the necessity of adding percutaneous posterior pedicle screw instrumentation in these cases.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; AP = anteroposterior; BMP = bone morphogenic protein; C7/SFD = C7 plumb line/sacro-femoral distance ratio; DDD = degenerative disc disease; LL = lumbar lordosis; PI = pelvic incidence; PT = pelvic tilt; rhBMP-2 = recombinant human bone morphogenetic protein 2; SS = sacral slope; SSA = spinosacral angle.

Article Information

Correspondence Arnaud Dubory: Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France. arnauddubory@hotmail.fr.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.SPINE181476.

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.

Headings

Figures

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    Illustration of the stand-alone ROI-A cage and Vertebridge plate stabilization device (Zimmer-LDR Medical) (A). Immediate postoperative anteroposterior (B) and lateral (C) standing lumbar spine films illustrating the stand-alone L5–S1 ALIF with both Vertebridge plates embedded in L5 and S1 vertebral bodies. Figure is available in color online only.

  • View in gallery

    Local sagittal measurements in a case of L5–S1 spondylolisthesis. A: Percentage of vertebral slippage (% L5 slip) corresponding to the ratio between the sagittal length of the discovered S1 inferior endplate (a) and the S1 superior endplate covered by L5 vertebra (b). B: L5–S1 disc angle corresponding to the angle between the inferior L5 endplate and the superior S1 endplate and segmental LL corresponding to the angle between the superior endplate of L5 and the superior endplate of S1. C: Posterior disc height ratio was calculated as the ratio between the posterior L5–S1 disc height (a) and the posterior L5 body height (b). D: S1 anchorage ratio corresponds to the S1 staple entry point into the S1 endplate. Figure is available in color online only.

  • View in gallery

    Study patient flowchart. iSPL = isthmic spondylolisthesis.

  • View in gallery

    Instrumentation failure after L5–S1 ALIF. A: Sacral endplate fracture (yellow arrow) in a Meyerding grade 2 isthmic spondylolisthesis in a 40-year-old female patient at 45 days after surgery. B: S1 plate breakage (yellow arrow) in a Meyerding grade 2 isthmic spondylolisthesis in a 47-year-old female patient at 6 months after surgery. Fusion occurred in both patients, at 13.9 and 11.2 months, respectively. C: Shape of the L5–S1 intervertebral space (red dashed line) in a patient with low-grade isthmic spondylolisthesis with a horizontal sacrum, a triangle-shaped L5–S1 intervertebral space, and a dysplastic sacral endplate, making the placement of the cage in the disc space difficult. D: Symptomatic DDD (yellow dashed line) with a vertical sacrum and a rectangle-shaped L5–S1 intervertebral space facilitating placement and primary stability of the ALIF cage. The angles (black dashed lines in panels C and D) represent the SS in each case. Figure is available in color online only.

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