Original ArticleStand-Alone Anterolateral Interbody Fusion Versus Extended Posterior Fusion for Symptomatic Adjacent-Segment Degeneration: A Retrospective Study of 2 Years' Follow-up
Introduction
Adjacent-segment degeneration (ASD) is very common after lumbar fusion. This phenomenon was first investigated more than 50 years ago in studies of the lumbar spine.1 Although the exact mechanism remains unclear, altered biomechanical stress and excessive distraction of disc space are considered to be risk factors for ASD.2, 3, 4, 5, 6 Several pathologic processes of ASD have been reported, including listhesis, instability, hypertrophic facet joint arthritis, nucleus pulposus herniation, and spinal stenosis.7, 8, 9 The radiologic incident rate varies from 8% to 100%, whereas symptomatic ASD requiring surgery ranges from 5.2% to 37.5%.2, 10, 11, 12 An increased risk of ASD requiring revision surgery is associated with the initial spinal disease, and the natural degenerative history has a significant effect on adjacent-segment pathology.13
Traditionally, the posterior approach involved laminectomy with or without extension of the instrumentation, and fusion was performed as a salvage surgery in lumbar reoperation including ASD.14, 15, 16, 17, 18 Severe scars resulting from previous surgery may be problematic.19 As such, anterior fusion, with the merits of being less invasive and avoiding posterior scars, has emerged as an alternative approach, including anterior lumbar interbody fusion (ALIF),20 lateral transposes interbody fusion (XLIF),21 and oblique lumbar interbody fusion (OLIF).22 Nevertheless, access-related complications such as vascular injury, nerve root jury, sympathetic dysfunction, and visceral injury are still inevitable when anterior fusion has been performed.23, 24 The surgical management of symptomatic ASD remains controversial, and controlled studies are still lacking.
Recently, we have proposed ALLIF (a modified form of OLIF; Figure 1) for lumbar disc herniation or even in lumbar revision surgery, and the results are satisfactory.25, 26 Therefore, we attempted to evaluate the clinical and radiologic outcome of stand-alone ALLIF in comparison with extended PLIF for symptomatic ASD resulting from posterior fusion in this study. To our knowledge, it is the first comparative study on this topic.
Section snippets
Inclusion and Exclusion Criteria
Patients who met the following criteria were included for analyses: 1) previous posterior fusion surgery for lumbar degenerative disease; 2) suffered from low back pain with or without radicular pain in the lower extremities; 3) failed conservative treatment such as bed rest, physical therapy, and analgesics for at least 3 months; 4) ASD including disc herniation, stenosis, and spondylolisthesis confirmed by radiologic images; 5) underwent stand-alone ALLIF or extended PLIF revision surgery;
Baseline Data
Baseline data are summarized in Table 1. This study involved a total of 13 patients in the ALLIF group (female/male: 8/5) and 27 cases (female/male: 12/15) in the PLIF group, with a mean age of 54.3 ± 6.6 years and 56.8 ± 7.1 years, respectively. There were no significant differences between the ALLIF and PLIF groups at baseline, including duration of follow-up, age, duration of symptoms, sex, body mass index, location of ASD, level of ASD, segments of previous fusion, pathologic type, VAS of
Discussion
ASD after lumbar fusion is a problematic sequela with a wide range of concerns.19 Symptomatic ASD required surgery ranged from 5.2% to 37.5%.2, 10, 11, 12 However, the best surgical management of symptomatic ASD still remains controversial. PLIF, ALIF, XLIF, and OLIF have been used in previous studies, but access-related complications are inevitable. Thus, we proposed ALLIF and initially attempted to evaluate the clinical and radiologic outcome of stand-alone ALLIF in comparison with extended
Conclusions
Stand-alone ALLIF could achieve satisfactory safety and efficacy for the treatment of symptomatic ASD. Back and leg pain, lumbar function, and quality of life are improved without a significant difference between ALLIF and PLIF. Notably, ALLIF could achieve a more effective restoration of DH with less trauma and faster recovery. In addition, cage subsidence seems greater, but the complication rate seems lower in ALLIF without significant differences. ALLIF may serve as a supplementary or
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Zhiming Tu and Lei Li contributed equally to this work; they are considered as co–first authors.