Clinical study
Clinical and radiologic outcomes of single-level direct lateral lumbar interbody fusion in patients with osteopenia

https://doi.org/10.1016/j.jocn.2019.03.004Get rights and content

Highlights

  • This article discusses direct lateral interbody fusion in patients with osteopenia.

  • Clinical and radiological outcomes were comparable in the osteopenia group.

  • DLIF is a reliable procedure for patients with osteopenia.

Abstract

Objective

Subsidence of the interbody graft into the vertebral bodies is one of the major complications of direct lateral interbody fusion (DLIF), resulting in pseudoarthrosis and severe pain. Low bone mineral density (BMD) has been known to increase the risk of subsidence. This study aims to determine whether or not the osteopenia should influence the surgical results in DLIF surgery.

Methods

We retrospectively reviewed the data collected prospectively on all patients who underwent single-level DLIF at our institution. A total of 84 patients were included in this study, comprised of 41 in the osteopenia group and 43 in the normal BMD group. The clinical and radiologic characteristics were compared at preoperative and postoperative 1 and 2 years.

Results

At postoperative two years, there was a statistically significant difference in disc height and intervertebral foramen height at index level between the two groups (p = 0.039, 0.044, respectively), but there was no significant difference in total lumbar lordosis (p = 0.179). At 24-month postoperative, 92.7% of the osteopenia group and 95.3% of the normal BMD group were solidly fused (p = 0.672). All postoperative clinical scores (VAS back pain, VAS leg pain, and ODI) improved similarly in both groups without significant difference. The overall incidence of cage subsidence with >3 mm was 17.1% in the osteopenia group and 9.3% in the normal BMD group (p = 0.345).

Conclusions

Patients with osteopenia who undergo single-level DLIF combined with posterior fixation exhibited comparable clinical and radiological outcomes as patients with normal BMD.

Introduction

In 2006, the direct lateral interbody fusion (DLIF) was introduced as an alternative to traditional approaches (anterior and posterior) to the lumbar spine [1]. A large and laterally placed implant maximizes contact with the apophyseal ring, aiding in disc height restoration and spinal alignment to promote ligamentotaxis for indirect decompression and biomechanical strength [2], [3]. The DLIF has been used as a practical option for the operative management of a wide range of spinal conditions including spinal deformity [4], [5], [6], [7].

The most common complications are hip flexor weakness and anterior thigh paresthesia due to injury to the psoas muscle and peripheral nerves (i.e., genitofemoral nerve) with an estimated incidence of 15–40% [8], [9], [10], [11]. Another common complication of the DLIF is subsidence of the interbody graft into the adjacent vertebral bodies, resulting in pseudoarthrosis, severe pain, fracture of the vertebral body, and a decrease of intervertebral foraminal height [12], [13], [14]. The subsidence rate was reported to be 0.3–30% [13], [14]. The occurrence of graft subsidence is considered to be a multifactorial process. Several risk factors have been investigated in the previous studies including endplate violation, insufficient cage width, inappropriate cage position, over distraction, and lateral plating [12], [13], [14], [15], [16]. Low bone mineral density (BMD), as measured by T score on dual-energy X-ray absorptiometry (DEXA), has also been reported as one of the risk factors for graft subsidence [17]. As the population ages, the number of people with osteopenia or osteoporosis who have undergone DLIF is increasing. However, to our knowledge, there are no reports of clinical studies about the relationship between osteopenia and its surgical results.

The present study was performed to determine whether or not the DEXA T score should influence the clinical and radiologic outcomes by comparing patients with osteopenia and those with normal BMD.

Section snippets

Patient population

Between May 2012 and November 2016, 207 consecutive patients underwent DLIF in our department (Fig. 1). The DLIF procedure was performed as previously described [18]. A PEEK cage filled with cancellous allograft bone chips mixed with bone marrow and percutaneous pedicle screws were used for all patients. Preoperative diagnosis were spinal stenosis with instability (97, 46.9% most common), degenerative spondylolisthesis (54, 26.1%), adjacent segmental disease (38, 18.4%), and complex scoliotic

Results

Demographic data of both groups are shown in Table 1. There were no significant statistical differences in sex, age, body mass index, diabetes, smoking status and follow-up months, except the BMD. The mean BMD (T-score) of the osteopenia group was −1.7 ± 0.4 and that of normal BMD group was −0.6 ± 0.6 (p < 0.001).

The surgical level, distribution of the cage location and characteristics in each group are shown in Table 2. In both groups, L4-5 surgery was the most common (32 patients in the

Discussion

The prevalence of osteoporosis and osteopenia in adults 50 years and older in the Republic of Korea has been reported [23]. It is an analysis of data from the Korea National Health and Nutrition Examination Survey 2008–2011. The prevalence of osteoporosis is 7.3% in men and 38.0% in women. The prevalence of osteopenia is 46.5% in men and 48.7% in women.

As life expectancy increases, elderly patients are undergoing spine surgery for a variety of conditions, including traumatic, oncologic,

Conclusion

Clinical and radiologic outcomes of single-level DLIF combined with posterior fixation in patients with osteopenia were comparable to that of patients with normal BMD. Therefore we could conclude that DLIF is a reliable procedure to treat lumbar degenerative disease for patients with osteopenia.

Conflict of interest

None.

Disclosure of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement

This research was supported by the Brain Research Program through the National Research Foundation of Korea(NRF) funded by the Ministry of Science and ICT (2016M3C7A1904984).

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