Topping-off technique for stabilization of lumbar degenerative instabilities in 322 patients

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OBJECTIVE

Semi-rigid instrumentation (SRI) was introduced to take advantage of the concept of load sharing in surgery for spinal stabilization. The authors investigated a topping-off technique in which interbody fusion is not performed in the uppermost motion segment, thus creating a smooth transition from stabilized to free motion segments. SRI using the topping-off technique also reduces the motion of the adjacent segments, which may reduce the risk of adjacent segment disease (ASD), a frequently observed sequela of instrumentation and fusion, but this technique may also increase the possibility of screw loosening (SL). In the present study the authors aimed to systematically evaluate reoperation rates, clinical outcomes, and potential risk factors and incidences of ASD and SL for this novel approach.

METHODS

The authors collected data for the first 322 patients enrolled at their institution from 2009 to 2015 who underwent surgery performed using the topping-off technique. Reoperation rates, patient satisfaction, and other outcome measures were evaluated. All patients underwent pedicle screw–based semi-rigid stabilization of the lumbar spine with a polyetheretherketone (PEEK) rod system.

RESULTS

Implantation of PEEK rods during revision surgery was performed in 59.9% of patients. A median of 3 motion segments (range 1–5 segments) were included and a median of 2 motion segments (range 0–4 segments) were fused. A total of 89.4% of patients underwent fusion, 73.3% by transforaminal lumbar interbody fusion (TLIF), 18.4% by anterior lumbar interbody fusion (ALIF), 3.1% by extreme lateral interbody fusion (XLIF), 0.3% by oblique lumbar interbody fusion (OLIF), and 4.9% by combined approaches in the same surgery. Combined radicular and lumbar pain according to a visual analog scale was reduced from 7.9 ± 1.0 to 4.0 ± 3.1, with 56.2% of patients indicating benefit from surgery. After maximum follow-up (4.3 ± 1.8 years), the reoperation rate was 16.4%.

CONCLUSIONS

The PEEK rod concept including the topping-off principle seems safe, with at least average patient satisfaction in this patient group. Considering the low rate of first-tier surgeries, the presented results seem at least comparable to those of most other series. Follow-up studies are needed to determine long-term outcomes, particularly with respect to ASD, which might be reduced by the presented approach.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; ASD = adjacent segment disease; DS = dynamic stabilization; OLIF = oblique lumbar interbody fusion; PEEK = polyetheretherketone; SL = screw loosening; SRI = semi-rigid instrumentation; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale; XLIF = extreme lateral interbody fusion.
Article Information

Contributor Notes

Correspondence Sandro M. Krieg: Technische Universität München, Munich, Germany. sandro.krieg@tum.de.INCLUDE WHEN CITING Published online November 15, 2019; DOI: 10.3171/2019.8.SPINE181434.Disclosures S.M.K. is a consultant for Brainlab, Spineart, and Nexstim and has received honoraria from Medtronic and Carl Zeiss Meditec. S.M.K. and B.M. received research grants from and are consultants for Brainlab. B.M. has received honoraria, consulting fees, and research grants from Medtronic, icotec ag, and Relievant Medsystems; honoraria and research grants from Ulrich Medical; honoraria and consulting fees from Spineart and DePuy Synthes; and royalties from Spineart. N.S. has received honoraria from Nexstim Plc.
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