Comparison of rod fracture rates in long spinal deformity constructs after transforaminal versus anterior lumbar interbody fusions: a single-institution analysis

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OBJECTIVE

Pseudarthrosis is a common complication of long-segment fusions after surgery for correction of adult spinal deformity (ASD). Interbody fusions are frequently used at the caudal levels of long-segment spinal deformity constructs as adjuncts for anterior column support. There is a paucity of literature comparing rod fracture rates (proxy for pseudarthrosis) in patients undergoing transforaminal lumbar interbody fusion (TLIF) versus anterior lumbar interbody fusion (ALIF) at the caudal levels of the long spinal deformity construct. In this study the authors sought to compare rod fracture rates in patients undergoing surgery for correction of ASD with TLIF versus ALIF at the caudal levels of long spinal deformity constructs.

METHODS

We reviewed clinical records of patients who underwent surgery for correction of ASD between 2008 and 2014 at a single institution. Data including demographics, comorbidities, and indications for surgery, as well as postoperative variables, were collected for each patient. All patients had a minimum 2-year follow-up. Patients were dichotomized into two groups for comparison on the basis of undergoing a TLIF versus an ALIF procedure at the caudal levels of long spinal deformity constructs. The primary outcome of interest was the rate of rod fractures.

RESULTS

A total of 198 patients (TLIF 133 patients; ALIF 65 patients) underwent a long-segment fusion to the sacrum with iliac fixation. The mean ± standard deviation follow-up period was 62.23 ± 29.26 months. Baseline demographic variables were similar in both patient groups. There were no significant differences between groups in the severity of the baseline sagittal plane deformity (i.e., baseline lumbar-pelvic parameters) or the final deformity correction achieved. Mean total recombinant human bone morphogenetic protein 2 (rhBMP-2) dose for L1–sacrum fusion was significantly higher in the ALIF (100 mg) than in the TLIF (62 mg) group. The overall rod failure rate (cases with rod fracture/total cases) within this case series was 19.19% (38/198); 10.60% (21/198) were unilateral rod fractures and 8.58% (17/198) were bilateral rod fractures. At last clinical follow-up, there were no statistically significant differences in bilateral rod fracture rates between the group of patients who had a TLIF procedure and the group who had an ALIF procedure at the caudal levels of the long spinal deformity constructs (TLIF 10.52% vs ALIF 4.61%, p = 0.11). However, the incidence rate (cases per patient follow-up years) for bilateral rod fractures was significantly higher in the TLIF than in the ALIF cohort (TLIF 2.20% vs ALIF 0.70%, p < 0.0001). The reoperation rate for rod fractures was similar between the patient groups (p = 0.40).

CONCLUSIONS

Although both ALIF and TLIF procedures at the caudal levels of long spinal deformity constructs achieved similar and satisfactory deformity correction, ALIFs were associated with a lower rod fracture incidence rate. There were no differences between groups in the prevalence of rod fracture or revision surgery, however, and both groups had low bilateral rod fracture prevalence and incidence rates. One technique is not clearly superior to the other.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; HRQOL = health-related quality of life; LL = lumbar lordosis; PI = pelvic incidence; PRO = patient-reported outcome; rhBMP-2 = recombinant human bone morphogenetic protein 2; SRS = Scoliosis Research Society; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion.
Article Information

Contributor Notes

Correspondence Munish C. Gupta: Washington University in St. Louis, School of Medicine, St. Louis, MO. munishgupta@wustl.edu.INCLUDE WHEN CITING Published online October 11, 2019; DOI: 10.3171/2019.7.SPINE19630.Disclosures Dr. Buchowski reports receiving royalties from Globus Medical, K2M, and Wolters Kluwer and receiving fellowship grant funding (paid directly to the institution) from OMeGA and AOSpine. Dr. Lenke reports being a paid consultant for Medtronic (monies donated to a charitable foundation); receiving royalties and reimbursement for airfare/hotel from BroadWater; receiving reimbursement for airfare/hotel from the Seattle Science Foundation; receiving reimbursement for airfare/hotel and grant support (monies to institution) from the Scoliosis Research Society; receiving reimbursement for airfare/hotel from Stryker Spine and the Spinal Research Foundation; receiving grant support (monies to institution) from EOS and the Setting Scoliosis Straight Foundation; serving as an expert witness in a patent infringement case for Fox Rothschild, LLC; receiving royalties from Quality Medical Publishing; receiving an Evans Family donation of philanthropic research funding from a grateful patient/family; receiving a Fox Family Foundation donation of philanthropic research funding from a grateful patient; and receiving reimbursement for airfare/hotel, grant support (monies to institution), and fellowship support (paid directly to institution) from AOSpine. Dr. Gupta reports serving as a consultant to DePuy and Medtronic; receiving royalties and travel reimbursement and serving on the advisory board for DePuy; receiving royalties from Innomed; receving stock options from perForm Biologics; receiving travel reimbursement from Alphatec and the Scoliosis Research Society; serving on the advisory board and receiving travel reimbursement from Medtronic; and receiving grants (paid directly to the institution) from AOSpine and OMeGA.
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