Effects of Cage Implantation Depth on Sagittal Parameters and Functional Outcomes in Posterior Lumbar Interbody Fusion for the Treatment of L4-L5 Lumbar Degenerative Spondylolisthesis

Abstract

Objective: In the treatment of lumbar degenerative spondylolisthesis (LDS) with Posterior lumbar interbody fusion (PLIF) surgery, interbody fusion implants play a key role in supporting the vertebral body and facilitating fusion. The objective of this study was to assess the impact of implantation depth on sagittal parameters and functional outcomes in patients undergoing PLIF surgery.

Methods: This study reviewed 128 patients with L4-L5 LDS between January 2016 and August 2019. All patients underwent an open PLIF surgery that included intravertebral decompression, implantation of pedicle screws and cage. We grouped according to the position of the center of the cage relative to the L5 vertebral endplate. Patients with the center of the cage located at the anterior 1/2 of the upper end plate of the L5 vertebral body were divided into Anterior group, and located at the posterior 1/2 of the upper end plate of the L5 vertebral body were divided into Posterior group. The lumbar lordosis (LL), segmental lordosis (SL), sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT) and slope degree (SD) was measured for radiographic outcomes. We used the visual analog scale (VAS) and the oswestry disability index (ODI) score to assess functional outcomes. Paired t-test was used to compare imaging and bedside data before and after surgery between the two groups, and independent sample t-test, χ² test and Fisher exact test were used to compare the data between the two groups.

Result: The mean follow-up of Anterior group was 44.13 ± 9.23 months, and Posterior group was 45.62 ± 10.29 months (P > 0.05). The LL, SL, PT, SS, SD and PI-LL after operation showed great improvements, relative to the corresponding preoperative values in both groups (P < 0.05). Compared to Posterior group, Anterior group exhibited far enhanced SL (15.49 ± 3.28 vs. 13.67 ± 2.53, P < 0.05), LL (53.47 ± 3.21 vs. 52.08 ± 3.15, P < 0.05) outcomes and showed depressed PI-LL (8.87 ± 5.05 vs. 10.73 ± 5.39, P < 0.05) outcomes at the final follow-up. Meanwhile, the SL in Anterior group (16.18 ± 3.99) 1 months after operation were also higher than in Posterior group (14.12 ± 3.57) (P < 0.05). We found that VAS and ODI at the final follow-up in Anterior group (3.62 ± 0.96, 25.19 ± 5.25) were significantly lower than those in Posterior group (4.12 ± 0.98, 27.68 ± 5.13) (P < 0.05).

Conclusions: For patients with LDS, the anteriorly placed cage may provide better improvement of SL after PLIF surgery. Meanwhile, the anteriorly placed cage may achieve better sagittal parameters of LL and PI-LL and functional outcomes at the final follow-up.

Keywords

Cage Position / Lumbar Degenerative Spondylolisthesis / Posterior Lumbar Interbody Fusion / Sagittal Parameters

References

[1] ZhouQ, ZhangJX, ZhengYF, Teng Y, YangHL, LiuH, et al. Effects of different pedicle screw insertion depths on sagittal balance of lumbar degenerative spondylolisthesis, a retrospective comparative study. BMC Musculoskelet Disord. 2021;22:850.

[2] ClowardRB. Posterior lumbar interbody fusion updated. Clin Orthop Relat Res. 1985;193:16–19.

[3] SugiuraT, OkudaS, TakenakaS, Nagamoto Y, MatsumotoT, TakahashiY, et al. Comparing investigation between bilateral partial laminectomy and posterior lumbar Interbody fusion for mild degenerative spondylolisthesis. Clin Spine Surg. 2021;34:E403–E409.

[4] ChanAK, BissonEF, BydonM, Glassman SD, FoleyKT, PottsEA, et al. A comparison of minimally invasive transforaminal lumbar interbody fusion and decompression alone for degenerative lumbar spondylolisthesis. Neurosurg Focus. 2019;46:E13.

[5] ChangMC, ChooYJ, LeeGW. Pedicle screws versus cortical screws in posterior lumbar interbody fusion surgery for degenerative spondylolisthesis: a systematic review and meta-analysis. The Spine. 2021;21:1126–1134.

[6] HumphreysSC, HodgesSD, PatwardhanAG, EckJC, MurphyRB, CovingtonLA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine. 2001;26:567–571.

[7] Le HuecJC, Faundez A, DominguezD, HoffmeyerP, Aunoble S. Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review. Int Orthop. 2015;39:87–95.

[8] MehtaVA, AminA, OmeisI, Gokaslan ZL, GottfriedON. Implications of spinopelvic alignment for the spine surgeon. Neurosurgery. 2015;76(Suppl 1):S42–S56. discussion S.

[9] WangDF, ChenXL, HanD, KongC, LuSB. The effect of sagittal alignment, coronal balance, and segmental stability on preoperative patient-reported outcomes in patients with degenerative lumbar spondylolisthesis. BMC Surg. 2023;23(1):48.

[10] LiangY, ZhaoY, XuS, ZhuZ, LiuH, MaoK. Effects of different orientations of cage implantation on lumbar Interbody fusion. World Neurosurg. 2020;140:e97–e104.

[11] DingQ, TangX, ZhangR, Wu H, LiuC. Do radiographic results of Transforaminal lumbar Interbody fusion vary with cage position in patients with degenerative lumbar diseases? Orthop Surg. 2022;14:730–741.

[12] JagannathanJ, SansurCA, OskouianRJ, Fu KM, ShaffreyCI. Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion. Neurosurgery. 2009;64:955–963. discussion 63–4, 964.

[13] KeplerCK, RihnJA, RadcliffKE, Patel AA, AndersonDG, VaccaroAR, et al. Restoration of lordosis and disk height after single-level transforaminal lumbar interbody fusion. Orthop Surg. 2012;4:15–20.

[14] MatsumotoT, OkudaS, MaenoT, Yamashita T, YamasakiR, SugiuraT, et al. Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion. J Neurosurg Spine. 2017;26:435–440.

[15] KimSB, JeonTS, HeoYM, Lee WS, YiJW, KimTK, et al. Radiographic results of single level transforaminal lumbar interbody fusion in degenerative lumbar spine disease: focusing on changes of segmental lordosis in fusion segment. Clin Orthop Surg. 2009;1:207–213.

[16] LandhamPR, DonAS, RobertsonPA. Do position and size matter? An analysis of cage and placement variables for optimum lordosis in PLIF reconstruction. Eur Spine J. 2017;26:2843–2850.

[17] KeplerCK, HuangRC, SharmaAK, Meredith DS, MetitiriO, SamaAA, et al. Factors influencing segmental lumbar lordosis after lateral transpsoas interbody fusion. Orthop Surg. 2012;4:71–75.

[18] Y ounYH, ChoKJ, NaY, KimJS. Global sagittal alignment and clinical outcomes after 1-3 short-segment lumbar fusion in degenerative spinal diseases. Asian. Spine J. 2022;16:551–559.

[19] ChoJH, HwangCJ, LeeDH, Lee CS. Using Lordotic cages at the L5-S1 level does not guarantee the improvement of sagittal alignment in patients who underwent posterior lumbar Interbody fusion. Asian Spine J. 2023;17(3):477–484.

[20] CunninghamBW, PollyDW. The use of interbody cage devices for spinal deformity: a biomechanical perspective. Clin Orthop Relat Res. 2002;394:73–83.

[21] GreimelF, Wolkerstorfer S, SpörrerJF, ZemanF, Hoffstetter P, GrifkaJ, et al. Radiological outcome of postoperative sagittal balance on standing radiographs in comparison to intraoperative radiographs in prone position when performing lumbar spinal fusion. Arch Orthop Trauma Surg. 2017;137:1319–1325.

[22] BoulayC, Tardieu C, HecquetJ, BenaimC, Mouilleseaux B, MartyC, et al. Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J. 2006;15:415–422.

[23] KimMK, LeeSH, KimES, Eoh W, ChungSS, LeeCS. The impact of sagittal balance on clinical results after posterior interbody fusion for patients with degenerative spondylolisthesis: a pilot study. BMC Musculoskelet Disord. 2011;12:69.

[24] PhanK, Nazareth A, HussainAK, DmytriwAA, Nambiar M, NguyenD, et al. Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique. Eur Spine J. 2018;27:1981–1991.

[25] KimWJ, MaCH, KimSH, Min YS, LeeJW, ChangSH, et al. Prevention of adjacent segmental disease after fusion in degenerative spinal disorder: correlation between segmental lumbar lordosis ratio and pelvic incidence-lumbar lordosis mismatch for a minimum 5-year follow-up. Asian Spine J. 2019;13:654–662.

[26] ZhengG, WangC, WangT, Hu W, JiQ, HuF, et al. Relationship between postoperative lordosis distribution index and adjacent segment disease following L4-S1 posterior lumbar interbody fusion. J Orthop Surg Res. 2020;15:129.

[27] IssaTZ, LeeY, LambrechtsMJ, TranKS, Trenchfield D, BakerS, et al. The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion. Neurosurg Focus. 2023;54(1):E7.

[28] YuanW, Kaliya-Perumal AK, ChouSM, OhJY. Does lumbar Interbody cage size influence subsidence? A Biomechanical Study. Spine. 2020;45:88–95.

[29] NemotoO, Asazuma T, YatoY, ImabayashiH, Yasuoka H, FujikawaA. Comparison of fusion rates following transforaminal lumbar interbody fusion using polyetheretherketone cages or titanium cages with transpedicular instrumentation. Eur Spine J. 2014;23:2150–2155.

[30] HongTH, ChoKJ, KimYT, Park JW, SeoBH, KimNC. Does lordotic angle of cage determine lumbar lordosis in lumbar interbody fusion? Spine. 2017;42:E775–E780.

[31] ZhuK, YanS, GuoS, TongJ, LiC, TanJ, et al. Morphological changes of contralateral intervertebral foramen induced by cage insertion orientation after unilateral transforaminal lumbar interbody fusion. J Orthop Surg Res. 2019;14:79.

RIGHTS & PERMISSIONS

2024 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.