Impact of sufficient contact between the autograft and endplate soon after surgery to prevent nonunion at 12 months following posterior lumbar interbody fusion

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  • 1 Departments of Orthopedic Surgery,
  • 7 Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, and
  • 8 Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka;
  • 2 Department of Orthopedic Surgery, International University of Health and Welfare, Narita, Chiba;
  • 3 Department of Orthopedic Surgery, University of Yamanashi, Chuo, Yamanashi;
  • 4 Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano;
  • 5 Department of Orthopedic Surgery, North Alps Medical Center Azumi Hospital, Kita Azumi, Nagano; and
  • 6 Department of Orthopedic Surgery, Narita Memorial Hospital, Aichi, Japan
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OBJECTIVE

Nonunion after posterior lumbar interbody fusion (PLIF) is associated with poor long-term outcomes in terms of health-related quality of life. Biomechanical factors in the fusion segment may influence spinal fusion rates. There are no reports on the relationship between intervertebral union and the absorption of autografts or vertebral endplates. Therefore, the purpose of this retrospective study was to evaluate the risk factors of nonunion after PLIF and identify preventive measures.

METHODS

The authors analyzed 138 patients who underwent 1-level PLIF between 2016 and 2018 (75 males, 63 females; mean age 67 years; minimum follow-up period 12 months). Lumbar CT images obtained soon after the surgery and at 6 and 12 months of follow-up were examined for the mean total occupancy rate of the autograft, presence of a translucent zone between the autograft and endplate (more than 50% of vertebral diameter), cage subsidence, and screw loosening. Complete intervertebral union was defined as the presence of both upper and lower complete fusion in the center cage regions on coronal and sagittal CT slices at 12 months postoperatively. Patients were classified into either union or nonunion groups.

RESULTS

Complete union after PLIF was observed in 62 patients (45%), while nonunion was observed in 76 patients (55%). The mean total occupancy rate of the autograft immediately after the surgery was higher in the union group than in the nonunion group (59% vs 53%; p = 0.046). At 12 months postoperatively, the total occupancy rate of the autograft had decreased by 5.4% in the union group and by 11.9% in the nonunion group (p = 0.020). A translucent zone between the autograft and endplate immediately after the surgery was observed in 14 and 38 patients (23% and 50%) in the union and nonunion groups, respectively (p = 0.001). The nonunion group had a significantly higher proportion of cases with cage subsidence and screw loosening at 12 months postoperatively in comparison to the union group (p = 0.010 and p = 0.009, respectively).

CONCLUSIONS

A lower occupancy rate of the autograft and the presence of a translucent zone between the autograft and endplate immediately after the surgery were associated with nonunion at 12 months after PLIF. It may be important to achieve sufficient contact between the autograft and endplate intraoperatively for osseous union enhancement and to avoid excessive absorption of the autograft. The achievement of complete intervertebral union may decrease the incidence of cage subsidence or screw loosening.

ABBREVIATIONS BMD = bone mineral density; HRQOL = health-related quality of life; ICC = intraclass correlation coefficient; ODI = Oswestry Disability Index; PEEK = polyetheretherketone; PLIF = posterior lumbar interbody fusion; rhBMP-2 = recombinant human bone morphogenetic protein–2; SEM = standard error of measurement; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

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Contributor Notes

Correspondence Hiroki Ushirozako: Hamamatsu University School of Medicine, Shizuoka, Japan. verisa0808@gmail.com.

INCLUDE WHEN CITING Published online August 7, 2020; DOI: 10.3171/2020.5.SPINE20360.

Disclosures Funding for this study was provided by B. Braun Aesculap. Dr. Yamato works at a donation-endowed laboratory in the Division of Geriatric Musculoskeletal Health. He has relevant financial relationships with Medtronic Sofamor Danek Inc., Japan Medical Dynamic Marketing Inc., and Meitoku Medical Institution, Jyuzen Memorial Hospital.

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