| Background:The goal of any surgical intervention is to reach clinical success with the least possible invasiveness andsurgical trauma. Lumbar intervertebral fusion is an established treatment for multiple pathologies of the lumbar spine.It can be performed by using an anterior-only lumbar interbody fusion (ALIF), posterior-only lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) or lateral lumbar interbody fusion (XLIF), although it remains debatable, which should be preferred.Fusion of lumbar motion segments currently represents the mainstay of surgical treatment for patients suffering from intractable low back pain (LBP) resulting from lumbardegenerative disc disease (DDD). The majority of fusion procedures are performed via posterior approaches, with or without instrumentation or additional interbody fusion techniques. However, a variety of negative side effects have been linked with both the posterior approachas well as the fusion of lumbar motion segments. These negative side effects include access-related collateral muscle damage, sagittal imbalance, graft site morbidity, screw loosening, pseudarthrosis, adjacent level facet jointviolations in posterior instrumented fusion techniques, high rates of adjacent level pathologies as well as considerable complication and reoperation rates.In an attempt to avoid the above mentioned and fusion related adverse effects, a variety of anterior lumbar interbody fusion (ALIF) devices have been introduced. PEEK-cages ALIF device is made of a non-absorbable biocompatible polyetheretherketone (PEEK) material that is radiolucent and has a modulus of elasticity similar to bone. It offers advantages over metal cages in load-bearing and may reduce the subsidence rate. Furthermore, due to its radiolucency, the interbody cages made of PEEK permit assessment of fusion in radiographs.It is an established treatment for structural instability associated with symptomatic disk degeneration. Despite numerous advantages, ALIF with a bone graft as a stand-alone procedure is associated with high rates of non-union (44%), subsidence, and graft extrusion. These complications are due to insufficient stability for vertebral interbody fusion.A combined anterior and posterior approach is often the preferred option, especially for adult spine deformity correction with severe low lumbar curvatures. Femoral ring allografts (FRAs) packed with autograft bone and combined with posterior instrumentation have shown promising fusion rates and sagittal lordosis restoration in spine deformities. This approach also avoids donor site morbidity. However, the bones are less stable at the endplate interface and often require supplemental anterior or posterior fixation. ALIF using PEEK cages has been reported in the treatment of adult spinal deformities in conjunction with posterior pedicle screw fixation. However, assessments such as the fusion rate, subsidence rate, cage migration, and the evaluation of harvested vertebrae have not been clearly documented in PEEK cages with local vertebral autografts in long fusions.And also, despite these potential advantages, previously published data on ALIF techniques applied on the DDD patients have reported controversial and at times contradictory results. The effectiveness of surgical therapy using ALIF and the outcome of different anterior lumbar fusion levels in patients with DDLBP is not clear. Furthermore, to the best of our knowledge, there are no previous studies evaluating the radiographic characteristics of PEEK cages packed with adjacent vertebral autograft material in lumbar ALIF in spinal deformity long fusion surgeries.The First ChapterRadiological evaluation of anterior lumbar fusion using PEEK cages with adjacent vertebral autograft in spinal deformity long fusion surgeriesObjective:The aim of this study was to evaluate the radiographic characteristics of PEEK cages packed with adjacent vertebral autograft material in lumbar ALIF in spinal deformity long fusion surgeries.Methods:This is a retrospective radiographic study. From April 2008 to April 2012,40 patients (5 males and 35 females, mean age 67±9 years) with coronal and/or sagittal spine deformities underwent staged corrective surgery combined with lumbar ALIF using PEEK cages at the L3-L4, L4-L5 or L5-S1 segment with posterior long (≥4 levels) instrumentation. The mean follow-up time was 27.5 months (13-49 months). We examined the interbody fusion rate and cage subsidence at 3 months postoperatively and final follow-up. Additionally, we evaluated the distance of cage migration at final follow-up and the improvement in lumbar lordosis. The rate of "collapse" of the adjacent vertebra where the autograft was harvested was assessed at the final follow-up. Finally, we examined the cage-related postoperative complications in this series.Results:Solid interbody fusion was achieved in 96.4% (81/84) of the levels at the final follow-up. Amild forward cage migration was observed, and the mean migration distance at final follow-up was 0.83 mm in L3/4,0.36 mm in L4/5 and 0.55 mm in L5/S1. There was cage subsidence observed in 8.3% (7/84) of the levels. In all patients, the PEEK cage maintained a significant increase in segmental lordosis at all postoperative visits. However, a mild reduction in segmental lordosis still occurred with time. The adjacent lumbar vertebral bodies where the autografts were harvested appeared to be intact in height radiologically at the final follow-up. There were no postoperative complications due to bone harvesting or cage insertion. Proximal junctional kyphosis was found in one patient who underwent a subsequent revision surgery.Conclusions:The use of lumbar ALIF with PEEK cages and adjacent vertebral autografts in spinal deformity long fusion surgeries is an effective and safe procedure. The allograft filler is safe and effective in maintaining the shape of harvested vertebrae. Additional long-term follow-up studies are needed to further justify its use.The Second ChapterAnterior lumbar interbody fusion for degenerative discogenic low back pain:Evaluation of L4-S1 fusionObjective:The treatment of degenerative discogenic pain is controversial, and anterior lumbar fusion for the treatment of degenerative discogenic low back pain (DLBP) has also been a controversial topic for over a generation.The aim of this systematic review was to evaluate the outcome of different anterior lumbar fusion levels for degenerative discogenic low back pain.Methods:In this study, we performed a clinical outcome sub-group analysis. The outcomes of 84 consecutive patients who underwent anterior lumbar interbody fusion (ALIF) from 2004 to 2009 were reviewed. The operative time,intraoperative blood loss, hospital stay, ODI,VAS results and complication rate were recorded separately.Medical indications were degenerative disc disease (DDD) (73.8%), post-discectomy disc disease (16.1%), and disc herniation (9.5%). Patients with severe spondylolysis or disc degeneration with more than three or multilevel lesions were excluded.Results:The mean operative time was 124.5±10.9 min (range 51-248). The mean intraoperative blood loss was 242.1±27.7 ml (range 50-2700). The mean hospital stay was 3.9±1.1 days (range 3-6d). The mean pre-operative VAS was 7.5±1.4, and the mean pre-operative ODI was 60.0±5.7.At the 1-year follow-up, the mean post-operative VAS was 3.3±1.3 and the mean post-operative ODI was 13.6±3.4 (P<0.05).L4-L5 disc fusion led to better clinical results than two-level L4-L5/L5-S1 disc fusion. Additionally, the two-level fusion of L4-L5/L5-S1 had better clinical results than L5-S1 disc fusion at both the 1-year and 2-year postoperative follow-up regarding the VAS score and ODI score. The rate of complications was more frequent in the two-level L4-L5/L5-S1 group (27.3%) (group C) than in the L4-L5 group (9.1%) (group A) and the L5-S1 group (12.5%) (group B). There was no difference between the L4-L5 group (9.1%) and the L5-S1 group (12.5%). A venous tear occurred during surgery and was successfully repaired in 6 of the 84 patients. There were 6 of 84 patients with pseudarthrosis during the follow-up, and these patients underwent a spinal fusion with instrumentation with a posterior approach after a mean of 1 year. The complications secondary to the surgical approach were persistent abdominal pain (1/84=1.2%) and wound dehiscence (1/84=1.2%).Conclusions:Anterior lumbar interbody fusion for L4-L5 had better clinical results than two segmental L4-L5/L5-S1 disc fusion,and two segmental L4-L5/L5-S1 disc fusion had better clinical results than L5-S1 disc fusion. Two segmental L4-L5/L5-S1 disc fusion has a higher complication rate (27.3%), but there was no difference between the L4-L5 group (9.1%) and L5-S1 group (12.5%).
|
PDF Full Text Request