Elsevier

World Neurosurgery

Volume 126, June 2019, Pages e1374-e1378
World Neurosurgery

Original Article
Comparison of Segmental Lordosis and Global Spinopelvic Alignment After Single-Level Lateral Lumbar Interbody Fusion or Transforaminal Lumbar Interbody Fusion

https://doi.org/10.1016/j.wneu.2019.03.106Get rights and content

Background

Lateral lumbar interbody fusion (LLIF) has steadily increased in popularity. Compared with the traditional transforaminal lumbar interbody fusion (TLIF), LLIF is thought to allow for greater improvement in lordosis. However, there are limited direct comparison data on the degree of regional and global alignment change after single-level LLIF and TLIF procedures. This study compared the changes in spinal sagittal alignment in patients who underwent either procedure.

Methods

A retrospective analysis of patients who underwent LLIF or TLIF for lumbar degenerative disease at a single institution was performed. Twenty patients who underwent single-level LLIF were matched to 20 patients who underwent single-level TLIF by gender and level of interbody fusion. All included patients had preoperative and postoperative standing scoliosis radiographs. Changes in segmental lordosis (SL) at the fused level, lumbar lordosis (LL), sagittal vertical axis, and pelvic incidence–LL mismatch (PI-LL) were measured. Statistical analysis was performed using paired and unpaired Student's t-tests. Means were reported with standard error.

Results

Within each group, 2, 4, and 14 patients had cages placed at L2-3, L3-4, and L4-5, respectively. The LLIF group demonstrated significantly increased SL compared with the TLIF group (+4.9° ± 3.0 vs. +2.6° ± 1.7, P = 0.01). LL, sagittal vertical axis, and PI-LL changes did not differ significantly between groups.

Conclusions

LLIF achieved greater improvements in SL than TLIF. However, regionally and globally, there were no significant differences with either procedure after a single-level intervention. The increased lordosis from LLIF compared with TLIF may be more impactful globally in multilevel fusions.

Introduction

Lumbar interbody fusion is now a common method to treat certain degenerative conditions such as refractory, symptomatic spondylolisthesis. Numerous approaches exist for obtaining interbody fusion including posterior, transforaminal, anterior, and lateral or oblique minimally invasive retroperitoneal. Each approach has its own risk-and-benefit profile.1

Some experts have suggested that lateral lumbar interbody fusion (LLIF) has the potential to achieve increased segmental lordosis (SL) and lumbar lordosis (LL) when compared with transforaminal lumbar interbody fusion (TLIF). Increased lordosis is an important radiographic parameter because sagittal alignment has been correlated with patient-reported outcomes, both preoperatively2, 3 and postoperatively.4 Given the purported advantage of LLIF over TLIF for segmental lordosis, this study compared the change in spinal sagittal alignment in patients who underwent either single-level LLIF or TLIF. It was hypothesized that LLIF would lead to increased segmental, regional, and global sagittal alignment.

Section snippets

Methods

Approval was obtained from the Institutional Review Board at the University of Michigan before conducting this study. We retrospectively identified 182 patients who underwent TLIF or LLIF since January 2014 at a single institution by a single surgeon. Both traditional open and minimally invasive surgery (MIS) TLIFs were identified and included because while the approaches differed, the critical portions of the procedure were similar, including facetectomy, diskectomy, end plate preparation,

Results

A total of 40 patients were analyzed, consisting of 20 patients in the LLIF group and 20 patients in the TLIF group. Four patients had interbody fusion performed at the L2-3 level, 8 patients at the L3-4 level, and 28 patients at the L4-5 level. Average patient radiographic follow-up was 14.6 months ± 6.1. There were no significant differences between groups in gender, age, levels treated, diagnosis, or baseline radiographic characteristics (Table 1).

Single-level LLIF resulted in a mean

Discussion

Over the past several years, there has been an increased focus on sagittal balance and spinopelvic parameters.6, 7 Furthermore, there is evidence that improved lumbar lordosis and segmental lordosis correlate with improved outcomes.8, 9, 10 Our results show that there is a significantly higher amount of SL achieved by single-level LLIF compared with single-level TLIF. However, our results do not show a statistically significant difference between single-level LLIF and TLIF in regional or global

Conclusion

Single-level LLIF resulted in greater improvements in segmental lordosis when compared with single-level TLIF. However, there was no difference in regional or global sagittal alignment with either procedure. These results suggest that the impact of a single-level fusion on regional or global alignment is limited.

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    Conflict of interest statement: P.P. is a consultant for Allosource, Globus Medical, NuVasive, and Medtronic and has received royalties from Globus Medical and research support from Pfizer and Vertex.

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