Lumbar spinal fusion

Since its initial description by Hibbs and Swift in 1929 1) , lumbar fusions have been widely used to correct structural defects and degeneration of the lumbar spine, a common ailment in the geriatric population 2) 3).

The past 2 decades have seen a considerable increase in the number of lumbar spinal fusion surgeries.

The most diffused surgical techniques for stabilization of the painful degenerated spine and lumbar instability, represented by transpedicular screws and rods instrumentation with or without interbody cages or disk replacements

The objective of lumbar spine fixation surgery is to stop motion at a painful spine segment, minimizing the pain and allowing the patients to increase their function 4) 5) 6).

see Lumbar fusion indications.

The mainly surgical techniques used are: posterior lumbar fusion (PLF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), oblique lumbar interbody fusion (OLIF) and Extreme Lateral lumbar interbody fusion (XLIF). These procedures, their indications, complications, and results are described in this narrative review.

Circumferential lumbar spinal fusion

see Lumbar interbody fusion.

see Open lumbar pedicle screw technique.

Non instrumented lumbar fusion.

Instrumented lumbar fusion.

Rehabilitation programmes using cognitive-behavioural intervention (CBT) are recommended. Further, initiating interventions preoperatively seems beneficial, but only limited data exists in the field of spine surgery.

Patients with degenerative disc disease or lumbar spondylolisthesis undergoing LF were randomized to usual care (control group) or preoperative CBT and usual care (CBT group). Primary outcome was change in Oswestry Disability Index (ODI) from baseline to 1-year follow-up. Secondary outcomes were catastrophizing, fear-avoidance belief, work status and back and leg pain.

At 1-year follow-up there was no statistically significant difference between the CBT group and the control group in ODI score (P = 0.082). However, the CBT group had achieved a significant reduction of -15 points (-26;-4) already at 3 months (between group difference P = 0.003) and this reduction was maintained throughout the year. There were no differences between groups at 1-year follow-up with regards to any of the secondary outcomes.

Participating in a preoperative CBT intervention in addition to usual care did not produce better outcomes at 1-year follow-up for patients undergoing LSF. Although the reduction in disability was achieved much faster in the CBT group, resulting in a significant difference between groups already three months after surgery, it did not translate into a faster return to work. This findings support the need for further research into the use of targeted rehabilitation interventions among patients with elevated levels of catastrophizing and fear avoidance beliefs 7).

Several commonly utilized MRI criteria proposed as indications for lumbar fusion do not seem to correlate with 2-year improvement in clinical outcomes. Discs which are narrowed and collapsed, preoperatively, demonstrate better improvement at 2 years postoperatively as compared to discs which have maintained disc height. Significant disc space collapse may represent a subset of “degenerative disc disease” which responds more favorably to treatment with fusion 8).

A lumbar fusion that includes L1 should not be terminated at L1 or T12.

The taller the disc space the less likely that posteriorly placed interbody grafts are well suited.

A. The disc may not be significantly degenerated to require discectomy

Patients undergoing fusion surgery at a single centre for LBP with a duration of more than 3 months were included. They were evaluated using the Short Form Health Survey version-2.0 (SF-36v2) and Oswestry Low Back Pain Disability Index (ODI) questionnaire preoperatively and 1 year after the surgical procedure to identify differences between genders and to evaluate correlations between disability and quality of life. Results:

We included 31 female and 30 male patients. The male patients had higher disability scores at the preoperative evaluation, but improved more than females in all domains of disability at the postoperative evaluation. HRQoL improved similarly in both genders. The ODI score showed a strong or moderate correlation with 6 of the domains of the SF-36 in males, but with only 3 domains in females. Surgery had a positive impact on the mental status of more men than women at risk of depression. Conclusion:

The type of benefit that surgery offers seems to be influenced by gender. While HRQoL improved in both genders, disability decreased significantly more in male patients. Male patients also showed a closer correlation between HRQoL and disability. We conclude that men and women place different importance on specific aspects of their overall quality of life 9).

A total of 1395 patients were identified and the overall 30-day complication rate was 11.47%. The complication rates were 9.04% and 14.05% for patients younger than 65 and older than 65, respectively. When stratified by decade cohorts, the complication rates were 9.04% for the <65 cohort, 13.46% for the 65 to 75 cohort, 16.17% for the >75 to 85 cohort, and 4.00% for the ≥85 cohort. Multivariable regression analysis revealed no statistically significant difference between the <65 and ≥65 age cohorts (odds ratio = 1.26; 95% confidence interval: 0.87-2.19). After stratifying into age cohorts, multivariable analyses revealed no difference in odds of postoperative complication occurrence for any age cohort when compared with the referent group (<65 years of age).

Patients older than 65 years of age have significantly higher rates of complications after lumbar fusion when compared to younger patients. However, multivariable analysis revealed that age was not an independent risk factor for complication occurrence after lumbar fusion 10).

Surgical stabilization of the lumbar spine is an effective treatment for lumbar spondylosis; in particular, for patients with severe chronic low back pain that has been resistant to three or more months of conservative therapy 11).

Failed solid bony fusion, or pseudarthrosis, is a well-known complication of lumbar arthrodesis. Recent advances in radiographic technology, biologics, instrumentation, surgical technique, and understanding of the local biology have all aided in the prevention and treatment of pseudarthrosis.

A systematic literature review was conducted using the MEDLINE and Embase databases in order to search for the current radiographie diagnosis and surgical treatment methods published in the literature (1985 to present). Inclusion criteria included: 1) published in English; 2) level of evidence I-III; 3) diagnosis of degenerative lumbar spine conditions and/or history of lumbar spine fusion surgery; and 4) comparative studies of 2 different surgical techniques or comparative studies of imaging modality versus surgical exploration.

Seven studies met the inclusion criteria for current radiographic imaging used to diagnose lumbar pseudarthrosis.

Plain radiographs and thin-cut CT scans were the most common method for radiographic diagnosis. PET has been shown to be a valid imaging modality for monitoring in vivo active bone formation. Eight studies compared the surgical techniques for managing and preventing failed lumbar fusion. The success rates for the treatment of pseudarthrosis are enhanced with the use of rigid instrumentation.

Spinal fusion rates have improved secondary to advances in biologies, instrumentation, surgical techniques, and understanding of local biology. Treatment of lumbar pseudarthrosis includes a variety of surgical options such as replacing loose instrumentation, use of more potent biologies, and interbody fusion techniques. Prevention and recognition are important tenets in the algorithm for the management of spinal pseudarthrosis 12).

Zdeblick TA. A prospective, randomized study of lumbar fusion. Preliminary results. Spine (Phila Pa 1976). 1993;18(8):983–991.
Endres S, Aigner R, Wilke A. Instrumented intervertebral or posterolateral fusion in elderly patients: clinical results of a single center. BMC Musculoskelet Disord. 2011;12:189.
Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976). 2005;30(12):1441–1445; discussion 1446-1447.
Bennett GJ, Serhan HA, Sorini PM, Willis BH. An experimental study of lumbar destabilization. Restabilization and bone density. Spine (Phila Pa 1976) 1997;22:1448–1453.
Esses SI, Sachs BL, Dreyzin V. Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine (Phila Pa 1976) 1993;18:2231–2238.
Schnee CL, Freese A, Ansell LV. Outcome analysis for adults with spondylolisthesis treated with posterolateral fusion and transpedicular screw fixation. J Neurosurg. 1997;86:56–63.
Rolving N, Nielsen CV, Christensen FB, Holm R, Bünger CE, Oestergaard LG. Does a Preoperative Cognitive-behavioural Intervention affect disability, pain behaviour, pain and return to work the first year after Lumbar Spinal Fusion Surgery? Spine (Phila Pa 1976). 2015 Feb 19. [Epub ahead of print] PubMed PMID: 25705964.
Djurasovic M, Carreon LY, Crawford CH 3rd, Zook JD, Bratcher KR, Glassman SD. The influence of preoperative MRI findings on lumbar fusion clinical outcomes. Eur Spine J. 2012 Aug;21(8):1616-23. doi: 10.1007/s00586-012-2244-9. Epub 2012 Mar 3. PubMed PMID: 22388983; PubMed Central PMCID: PMC3535247.
Ungureanu G, Chitu A, Iancu I, Kakucs C, Maior T, Florian IS. Gender Differences in the Self-assessment of Quality of Life and Disability After Spinal Fusion for Chronic Low Back Pain at a Neurosurgical Center in Eastern Europe. Neurospine. 2018 Aug 29. doi: 10.14245/ns.1836076.038. [Epub ahead of print] PubMed PMID: 30157581.
Bydon M, Abt NB, De la Garza-Ramos R, Olorundare IO, McGovern K, Sciubba DM, Gokaslan ZL, Bydon A. Impact of Age on Short-term Outcomes After Lumbar Fusion: An Analysis of 1395 Patients Stratified by Decade Cohorts. Neurosurgery. 2015 Sep;77(3):347-54. doi: 10.1227/NEU.0000000000000852. PubMed PMID: 26200912.
Noshchenko A, Hoffecker L, Lindley EM, Burger EL, Cain CM, Patel VV. Long Term Treatment Effects of Lumbar Arthrodeses in Degenerative Disc Disease: A Systematic Review with Meta Analysis. J Spinal Disord Tech. 2014 Jun 4. [Epub ahead of print] PubMed PMID: 24901878.
Chun DS, Baker KC, Hsu WK. Lumbar pseudarthrosis: a review of current diagnosis and treatment. Neurosurg Focus. 2015 Oct;39(4):E10. doi: 10.3171/2015.7.FOCUS15292. PubMed PMID: 26424334.
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