Do intraoperative radiographs predict final lumbar sagittal alignment following single-level transforaminal lumbar interbody fusion?

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The study aimed to determine if the intraoperative segmental lordosis (as calculated on a cross-table lateral radiograph following a single-level transforaminal lumbar interbody fusion [TLIF] for degenerative spondylolisthesis/low-grade isthmic spondylolisthesis) is maintained at discharge and at 6 months postsurgery.


The authors reviewed images and medical records of patients ≥ 16 years of age with a diagnosis of an isolated single-level, low-grade spondylolisthesis (degenerative or isthmic) with symptomatic spinal stenosis treated between January 2008 and April 2014. Age, sex, surgical level, surgical approach, and facetectomy (unilateral vs bilateral) were recorded. Upright standardized preoperative, early, and 6-month postoperative radiographs, as well as intraoperative lateral radiographs, were analyzed for the pelvic incidence, segmental lumbar lordosis (SLL) at the TILF level, and total LL (TLL). In addition, the anteroposterior position of the cage in the disc space was documented. Data are presented as the mean ± SD; a p value < 0.05 was considered significant.


Eighty-four patients were included in the study. The mean age of patients was 56.8 ± 13.7 years, and 46 patients (55%) were men. The mean pelvic incidence was 59.7° ± 11.9°, and a posterior midline approach was used in 47 cases (56%). All TLIF procedures were single level using a bullet-shaped cage. A bilateral facetectomy was performed in 17 patients (20.2%), and 89.3% of procedures were done at the L4–5 and L5–S1 segments. SLL significantly improved intraoperatively from 15.8° ± 7.5° to 20.9° ± 7.7°, but the correction was lost after ambulation. Compared with preoperative values, at 6 months the change in SLL was modest at 1.8° ± 6.7° (p = 0.025), whereas TLL increased by 4.3° ± 9.6° (p < 0.001). The anteroposterior position of the cage, approach, level of surgery, and use of a bilateral facetectomy did not significantly affect postoperative LL.


Following a single-level TLIF procedure using a bullet-shaped cage, the intraoperative improvement in SLL is largely lost after ambulation. The improvement in TLL over time is probably due to the decompression part of the procedure. The approach, level of surgery, bilateral facetectomy, and position of the cage do not seem to have a significant effect on LL achieved postoperatively.

ABBREVIATIONS LL = lumbar lordosis; PI = pelvic incidence; SLL = segmental LL; TLIF = transforaminal lumbar interbody fusion; TLL = total LL.

Article Information

Correspondence Khalid M. I. Salem: Blusson Spinal Cord Center, Vancouver, BC, Canada.

INCLUDE WHEN CITING Published online February 16, 2018; DOI: 10.3171/2017.8.SPINE161231.

Disclosures C.G.F. is a consultant for Medtronic and NuVasive. He receives royalties from Medtronic as well as fellowship program support that is paid by Medtronic to his institution. He also receives fellowship program support that is paid by AOSpine to his institution. He receives grant funding from OREF that is paid to his institution.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Calculating the PI and SLL. Lines marked with an a were used to measure SLL, and lines marked with a b were used to measure the PI.

  • View in gallery

    Calculating the position of the cage within the disc space. The cage position relative to the rostral endplate was calculated as (ab/ac) × 100, and the cage position relative to the caudal endplate was calculated as (fe/fd) × 100.

  • View in gallery

    The change in SLL. Stars represent a statistically significant change. Figure is available in color online only.

  • View in gallery

    The change in TLL. The star represents a statistically significant change. Figure is available in color online only.



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