Radiographic and clinical outcomes in one- and two-level transforaminal lumbar interbody fusions: a comparison of bullet versus banana cages

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  • 1 Department of Neurosurgery, The Ohio State University School of Medicine, Columbus; and
  • | 2 The Ohio State University School of Medicine, Columbus, Ohio
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OBJECTIVE

The aim of this study was to determine whether cage morphology influences clinical and radiographic outcomes following short-segment transforaminal lumbar interbody fusion (TLIF) procedures.

METHODS

The authors retrospectively reviewed one- and two-level TLIFs at a single tertiary care center between August 2012 and November 2019 with a minimum 1-year radiographic and clinical follow-up. Two cohorts were compared based on interbody cage morphology: steerable “banana” cage or straight “bullet” cage. Patient-reported outcome measures (PROMs), radiographs, and complications were analyzed.

RESULTS

A total of 135 patients with 177 interbody levels were identified; 45 patients had 52 straight cages and 90 patients had 125 steerable cages. Segmental lordosis increased with steerable cages, while it decreased with straight cages (+3.8 ± 4.6 vs −1.9 ± 4.3, p < 0.001). Conversely, the mean segmental lordosis of adjacent lumbar levels decreased in the former group, while it increased in the latter group (−0.52 ± 1.9 vs +0.52 ± 2.1, p = 0.004). This reciprocal relationship results in global sagittal parameters, including pelvic incidence minus lumbar lordosis and lumbar distribution index, which did not change after surgery with either cage morphology. Multivariate analysis confirmed that steerable cage morphology, anterior cage positioning, and less preoperative index-level segmental lordosis were associated with greater improvement in index-level segmental lordosis. PROMs were improved after surgery with both cage types, and the degree of improvement did not differ between cohorts (p > 0.05). Perioperative and radiographic complications were similar between cohorts (p > 0.05). Overall reoperation rates, as well as reoperation rates for adjacent-segment disease within 2 years of surgery, were not significantly different between cohorts.

CONCLUSIONS

Steerable cages are more likely to lie within the anterior disc space, thus increasing index-level segmental lordosis, which is accompanied by a reciprocal change in segmental alignment at the adjacent lumbar levels. The converse relationship occurs for straight cages, with a kyphotic change at the index levels and reciprocal lordosis occurring at adjacent levels.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; ASD = adjacent-segment disease; BMP = bone morphogenetic protein; EBL = estimated blood loss; LDDD = lumbar degenerative disc disease; LDI = lumbar distribution index; LL = lumbar lordosis; NRS = numeric rating scale; ODI = Oswestry Disability Index; PEEK = polyetheretherketone; PI = pelvic incidence; PI-LL = PI minus LL; PLIF = posterior lumbar interbody fusion; PROM = patient-reported outcome measure; PT = pelvic tilt; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

Supplementary Materials

    • Supplemental Figure and Tables (PDF 12,377 KB)

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