Article Figures & Data
Figures
- Figure 1
Flow diagram of the study selection process.
- Figure 2
Box-and-whisker plots of the data presented in Table 2, including the first, median, and third quartiles of subsidence occurrence for each surgery method. The whiskers indicate the ranges. Includes results from 6 anterior lumbar intervertebral fusion (ALIF), 11 lateral lumbar intervertebral fusion (LLIF), 8 LLIF with posterior fixation (LLIF-P), 7 oblique lumbar interbody fusion with posterior fixation (OLIF-P), 5 posterior lumbar interbody fusion with posterior fixation (PLIF-P), and 14 transverse lumbar interbody fusion with posterior fixation (TLIF-P) studies.
Tables
Surgical Procedure Description ALIF The ALIF technique consists of an anterior retroperitoneal approach that provides access to the disc, with the patient in supine position. It involves a 3- to 5-inch midline and paramedian incision, the opening of the longitudinal ligament, and an important vascular mobilization, leaving the paraspinal muscles intact.2,3 This approach allows the insertion of a cage that covers the entire endplate surface, including the apophyseal ring, which stabilizes the motion segments, which may not require adjunct pedicle screws. LLIF LLIF is performed by a lateral retroperitoneal incision on a laterally positioned patient. This creates a transpsoas corridor to access the disc space and insert the implant.2 Like the cages used in ALIF, the LLIF implant is placed medially and has a large footprint covering parts of the apophyseal ring. OLIF The OLIF surgery requires patients to be positioned on their side. It involves a lateral and paramedian incision between the peritoneum and the psoas muscle to access the disc space.2 A smaller implant than for ALIF and LLIF is inserted, covering the interior one-third portion of the endplate. It will rarely cover the apophyseal ring and mostly be used in conjunction with posterior fixations. PLIF PLIF, one of the first procedures used for IVD fusion surgery, accesses the IVD space from a posterior direction with the patient in a prone position. A midline incision dissecting bilateral muscle strip or splitting paramedian muscle is performed. Before inserting the cage, a laminectomy and a partial facetectomy are performed to navigate around nerve roots.4 Depending on the cage design, 1 or 2 cages are inserted within the apophyseal ring.2–4 TLIF The transforaminal TLIF provides access to the intervertebral space directly through a small unilateral incision on 1 side of the neural foramen while the patient is in prone position, minimizing nerve manipulation.2 This may involve extensive muscle retraction and dissection with the removal of the facet joint in order to place a straight or curved cage. TLIF cages have significantly smaller footprint coverage than ALIF and LLIF cages.3,5 Depending on the cage used and the surgeon’s approach, the TLIF cage can either be placed on the interior or medial part of the endplate. TLIF does not provide enough segmental stability without the use of posterior fixation. Abbreviations: ALIF, anterior lumbar interbody fusion; IVD, intervertebral disc; LLIF, lateral lumbar interbody fusion; OLIF, oblique lumbar interbody fusion; PLIF, posterior lumbar interbody fusion; TLIF, transverse lumbar interbody fusion.
Authors (Year) No. of Patients
at Final Follow-UpNo. of Levels Postoperative Follow-Up Pedicle Screws Implant Type Subsidence Considered Subsidence Occurrence Pathology Criteria Radiological Assessments Clinical Assessments ALIF Behrbalk et al (2013)18 25 32 2, 6, 12, and 18 mo No PEEK (Synthes SynFix-LR) cage >1 mm 5/32 (15.6%)a Only patients with grade 1 degenerative spondylolisthesis were included CT or x-ray imaging N/A Kuang et al (2017)26 42 50 3, 12, and 24 mo No Self-anchored stand-alone PEEK cage (ROI-A Oblique; LDR Medical) Any compromise to the endplate 3/50 (6%)a All spinal pathology considered
Excluded high BMI (≥28 kg/m2), severe osteoporosis, spinal stenosis, disc herniation, and spondylolisthesisCT or x-ray imaging N/A Lee et al (2017)27 26 26 12 and 24 mo No Synfix PEEK cage (Synthes) Any breakage of the endplate 4/26 (15.4%) Included patients with lower back pain, severe disc space narrowing, and moderate grade of spondylolisthesis;
excluded patients with deformity, history of lumbar surgery, or ossification of the ligamentum flavumCT VAS Phan et al (2017)28 137 N/A 6 wk No SynFix-LR PEEK integral cage device (Depuy) >2 mm <49 y old
2/45 (4.4%)
50–63 y old
2/46 (4.3%)
>64 y old
10/46 (21.7%)
No age consideration
14/137 (10.2%)All spinal pathology considered CT ODI and SF-12 Rao et al (2017)29 147 N/A 6 wk and 18 mo No SynFix-LR PEEK integral (Depuy) for 89.1% of the patients >2 mm 15/147 (10.2%) All spinal pathology considered CT and x-ray imaging ODI, VAS, and SF-12 Tu et al (2018)30 13 N/A 3, 12, and 24 mo No PEEK cages (ROI-A Oblique; LDR Medical) >2 mm 3/13 (23.1%) Included patients with ASD, all patients with additional spinal pathologies that were not severe were also included CT and x-ray imaging VAS, ODI, SF-36, and Macnab criteria LLIF Marchi et al (2013)12 74 98 2, 6 wk, 3, 6, and 12 mo No 46 with standard cages (18 mm)
28 with wide cages (22 mm) (CoRoent, NuVasive)High grade; >50% cage collapsed in the endplate 30%a for the standard cages and 11%a for the wide cages Most spinal pathology included; excluded patients with damaged spine structure, compromised vertebral bodies, presence of neuromuscular disease, severe central stenosis, and significant instability and scoliosis CT VAS and ODI Tohmeh et al (2014)31 140 223 12 mo minimum (average last follow-up at 15.5 mo) Yes 18- and 22-mm PEEK cages (CoRoent;
NuVasive)>1 mm,
2–4 mm,
>4 mm>1 mm; 15/223 (6.7%)a
2–4 mm; 71/223 (31.8%)a
>4 mm; 53/223 (23.8%)aAll spinal pathology considered Fluoroscopy and CT ODI, VAS, and SF-36 Kotwal et al (2015)32 118 237 Minimum of 24 mo (average last follow-up at 27.5 mo) Yes PEEK cages (Nuvasive) for 112 patients and carbon fiber cages (Depuy Spine) for 6 patients >2 mm 34/237 (14.3%)a Included neurological claudication with deformity or instability, scoliosis, spondylolisthesis, and junctional disc degeneration X-ray imaging VAS, ODI, and SF-12 Malham et al (2015)33 b 128 178 6 wk and 3, 6, and 12 mo (average last follow-up at 25.1 mo) 56 without and 72 with fixations PEEK cages with 18- and 22-mm width (NuVasive) Compromised endplate 13/125 (10.4%)
6 had pedicle screws and 7 didn’t have the posterior fixationAll spinal pathology considered CT VAS, ODI, and SF-36 Tempel et al (2015)34 335 712 12 mo No 22-mm wide PEEK cages A loss of more than 25% of the disc height 29/335 (8.7%) patients with subsidence All spinal pathology considered X-ray imaging N/A Isaacs et al (2016)35 29 36 6, 12 wk, 6, 12, and 24 mo Yes 16 patients with 18-mm width titanium cages (CoRoent XL, NuVasive), 86 patients with 18-mm width PEEK XLIF (NuVasive) >3 mm 1/30 (3.3%) Only patients with grade I or II degenerative spondylolisthesis were considered CT (12 mo) VAS, ODI, and SF-36 Yen et al (2017)10 140 247 1, 3, 6, and 12 mo 37.1% No 62.9% Yes 18–22-mm wide 50–60-mm long PEEK cages A loss of more than 25% of the disc height 22/79 (27.8%)a without pedicle screws,
30/168 (17.9%)a with pedicle screwsAll spinal pathology considered X-ray imaging N/A Du et al (2017)36 39 39 6 mo Yes 18–22-mm wide cages Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade; 2/39 (5%)
High grade; 0%All spinal pathology considered X-ray imaging ODI, VAS, and SF-12 Bocahut et al (2018)9 69 82 12 mo No Avenue L cage (Zimmer) >4 mm 20/63 (32%) All spinal pathology considered CT imaging VAS and ODI Tempel et al (2018)34 297 623 6 wk, 3, 6, 12, and 24 mo No 18-h and 22-mm wide PEEK Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade;
12/297 (4.04%)
High grade; 22/297 (7.4%)All spinal pathology considered X-ray imaging and CT N/A Chen et al (2019)23 107 126 3 d, 3, 12, and 24 mo No PEEK cages Low grade; >25% cage collapsed
High grade; >50% cage collapsed in the endplateHigh grade; (26.9%) Included all patients with degenerative disease X-ray imaging and CT JOA and VAS Jung et al (2019)37 84 84 1, 3, 6, 12, and 24 mo Yes PEEK cages >3 mm Patients with osteopenia 7/41 (17.1%)
Patients with normal bone mineral density 4/43 (9.3%)All spinal pathology considered X-ray imaging VAS and ODI Ko et al (2019)38 29 29 Minimum of 12 mo (average last follow-up at 33.6 mo) Yes PEEK with titanium coating Clydesdale cage (Medtronic) >2 mm 6/29 (20.7%) Included only patients with degenerative spondylolisthesis X-ray imaging VAS and ODI Park et al (2019)39 40 62 3 and 24 mo No N/A Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade;
11/62 (17.7%)a
High grade; 8/62 (12.9%)aIncluded only patients with ASD needing revision surgery X-ray imaging VAS and ODI Rentenberger et al (2019)40 122 258 12 mo No PEEK cage Nuvasive Inc. or COUGAR system (Depuy) High grade; >50% cage collapsed in the endplate High grade; 69/258 (26.7%)a All spinal pathology considered X-ray imaging and CT N/A Agarwal et al (2020)41 297 623 6 wk, 3, 6, 12, and 24 mo No 18- and 22-mm cages Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade;
10/297 (3.4%)
High grade; 20/297 (6.7%)All spinal pathology considered X-ray imaging N/A Okano et al (2020)42 96 210 Between 6 and 12 mo No PEEK cage (Nuvasive) or COUGAR system (Depuy Spine) High grade; >50% cage collapsed in the endplate 38/96 (39.6%)
58/210 (27.6%)aAll spinal pathology considered X-ray imaging or CT N/A OLIF Woods et al (2017)43 137 340 6 mo Yes PEEK with titanium coating (Medtronic CLYDESDALE) Any breach of the endplate adjacent to disc space 6/137 (4.4%) All spinal pathology considered CT and x-ray imaging N/A Lin et al (2018)44 25 25 6, 12, and 24 mo Yes PEEK Clydesdale; (Medtronic) >2 mm 3/20 (15%) All spinal pathology considered
Excluded patients with severe canal stenosis, spinal tumor, infection, fractures, and previous L4-L5 surgeryX-ray imaging VAS and ODI Chang et al (2019)45 169 262 3, 6, and 12 mo Yes PEEK cages >25% cage collapsed in the endplate 62/168 (36.9%)
85/261 (32.6%)aAll spinal pathology considered X-ray imaging ODI, SF-36, VAS, and JOA back pain evaluation questionnaire Lin et al (2019)13 67 107 6, 12, and 24 mo Yes 18–22-mm wide, 8–16-mm high, 40–55-mm long, PEEK cages Clydesdale (Medtronic) >3 mm 19/107 (17.8%)a Included all degenerative spinal disease
Excluded infection, trauma, neoplasm, and patient with previous lumbar surgeryCT VAS, ODI, and Macnab criteria Liu and Feng (2019)46 14 20 Minimum of 12 mo (last follow-up in the range of 12–45 mo) Yes (Clydesdale Spinal System, Medtronic) >25% cage collapsed in the endplate 1/14 (7.1%) Included all degenerative spinal disease
Excluded infection, spinal tumor, vertebral fracture, hypertrophic ligamentum flavum, lesions involving L5-S1, fused facet, and patient with severe spondylolisthesisX-ray imaging VAS and ODI Mun et al (2019)47 74 74 Minimum 6 mo (average last follow-up at 12.1 mo) Yes Large round PEEK cage (Perimeter, Medtronic) >2 mm (25.3%) All spinal pathology considered
Excluded patient with infection, tumor, and congenital anomaliesX-ray imaging VAS and ODI Wen et al (2019)48 74 74 24 mo Yes;
bilateral and uni-lateralN/A High grade; >50% cage collapsed in the endplate High grade; 13/74 (17.6%) All spinal pathology considered
Excluded high BMI (≥35 kg/m2), severe osteoporosis, lumbar infection, lumbar tumor, and patient with previous lumbar surgeryX-ray imaging VAS and ODI PLIF Suzuki et al (2013)49 19 19 Minimum 12 mo (average last follow-up at 54.6 mo) Yes 2 PEEK, parallelepiped (REC) cages 16.4–14.6 wide 12.0–11.0 high (Telamon-S/-C/-, 22.0 mm length; Medtronic) or Brantigan I/F cage 11.0 mm wide, 11.0 mm height, 23.0 mm length (Depuy, Raynhem) >2 mm 3/19 (15.8%) Included patients with osteoporotic vertebral collapse with neurologic deficit X-ray imaging VAS Lee et al (2017)27 30 30 12 and 24 mo Yes 2 PEEK cages (Medtronic) Any breakage of the endplate 3/30 (10%) Included patients with lower back pain, leg pain, neurogenic intermittent claudication, moderate disc space narrowing, and severe grade of spondylolisthesis
Excluded, patient with deformity, with history of lumbar surgery, and ossification of the ligamentum flavumCT imaging VAS Oh et al (2017)50 129 139 3, 6, and 12 mo; Minimum of 12 mo (average last follow-up at 49.2 mo) Yes PEEK cage (O.I.C. cages; Stryker) 1–3 and >3 mm >3 mm 22/139 (15.8%)a All spinal pathology considered CT imaging VAS, ODI, and SF-36 Tu et al (2018)30 27 N/A 3, 12, and 24 mo Yes PEEK cages (Libeier; Orthopedic) >2 mm 2/27 (7.4%) Included patients with ASD (all patients with additional spinal pathologies who were not severe were also included) CT VAS, ODI, SF-36, and Macnab criteria Park et al (2019)39 40 44 3 and 24 mo Yes N/A Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade;
10/44 (22.7%)a
High grade; 4/44 (9.1%)aIncluded only patients with ASD needing revision surgery X-ray imaging VAS and ODI TLIF Kim et al (2013)14 104 122 Minimum 24 mo (last follow-up range from 24 to 45 mo) Yes Bullet-shaped PEEK cage (Capstone; Medtronic) >2 mm >2 mm; 10/122 (8.2%)a
>4 mm; 8/122 (6.6%)aAll spinal pathology considered X-ray imaging N/A Isaacs et al (2016)35 26 29 6, 12 wk; 6, 12, and 24 mo Yes PEEK cages >3 mm 2/26 (7.7%) Included only patients with grade I or II degenerative spondylolisthesis CT (12 mo) and magnetic resonance imaging (3 mo) VAS, ODI, and SF-36 Choi et al (2016)51 21 21 6 and 12 mo Yes Banana-shaped cage (Crescent, Medtronic) or
straight cage (Opal, Depuy)>2 mm 7/21 (33.3%) All spinal pathology considered X-ray imaging and CT VAS, ODI, and patient satisfaction rate Kuang et al (2017)26 40 48 3, 12, and 24 mo Yes PEEK cage (Libeier) Any compromise to the endplate No cage subsidence Most spinal pathology considered
Excluded high BMI (≥28 kg/m2), severe osteoporosis, spinal stenosis, disc herniation, and spondylolisthesisCT or x-ray imaging Lee et al (2017)27 21 21 12 and 24 mo Yes PEEK Capstone cage (Medtronic) Any breakage of the endplate 8/21 (38.1%) Included patients with lower back pain, leg pain, moderate disc space narrowing, and unilateral intervertebral foraminal stenosis
Excluded, patients with deformity, with history of lumbar surgery, or ossification of the ligament flavumCT VAS score Lin et al (2017)11 76 76 3, 6, 12, and 24 mo Yes Banana-shaped cage or straight cage >2 mm 14/30 (46.7%) Included symptomatic spinal stenosis, grade I and II spondylolisthesis, herniated nucleus pulposus, and other clinical symptoms
Excluded patients with previous lumbar surgeryCT VAS and ODI Choi et al (2018)52 84 84 6 and 12 mo Yes Banana-shaped cage (Crescent, Medtronic)
Straight cage (Opal, Depuy)>2 mm Banana-shaped;
14/44 (31.8%)
Straight cages;
7/40 (17.5%)All spinal pathology considered
Excluded patients with metabolic bone disease, infection, spinal trauma, and tumorsX-ray imaging VAS and ODI Lin et al (2018)44 25 25 6, 12, and 24 mo Yes PEEK Opal (Depuy) or PEEK Capstone (Medtronic) >2 mm 6/20 (30%) Most spinal pathology considered
Excluded patients with severe canal stenosis, spinal tumor, infection, fractures, and previous L4-L5 surgeryX-ray imaging VAS and ODI Pereira et al (2018)7 117 117 6 and 12 mo Yes Bullet-shaped PEEK cage >3 mm 25/117 (21.4%) All spinal pathology considered
Excluded patients with infection, tumor, trauma, and previous lumbar surgeryCT ODI, Odom criteria, and Stanford score Ko et al (2019)38 41 41 Minimum 12 mo (average last follow-up at 27.2 mo) Yes PEEK capstone cage (Medtronic) >2 mm 21/41 (51.2%) Included only patients with degenerative spondylolisthesis X-ray imaging and CT VAS and ODI Mun et al (2019)47 74 74 Minimum 6 mo (average last follow-up at 22.3 mo) Yes A single (PEEK) cage (Capstone, Medtronic) >2 mm (25.3%) All spinal pathology considered
Excluded patients with infection, tumor, and congenital anomaliesX-ray imaging VAS and ODI Park et al (2019)53 784 881 18 mo Yes INNESIS PEEK cages (BK MEDITECH)
Rotation-type cages (PLIVIOS PEEK cages [Depuy, Raynham])
Bullet-shaped cages (Capstone PEEK cages [Medtronic])>2 mm 36/881 (4.1%)a All spinal pathology considered X-ray imaging N/A Zhou et al (2019)54 145 145 3, 6, and 12 mo Yes PEEK cage (Capstone, Medtronic) >2 mm 23/145 (15.9%) All spinal pathology considered
Excluded patients with infection, tumor, trauma, and previous lumbar surgeryX-ray and CT imaging VAS and ODI Zhao et al
(2020)576 76 60 mo Contoured and straight rod PEEK material and cuboid shape (arched appearance) from Stryker Low grade; >25% cage collapsed in the endplate
High grade; >50% cage collapsed in the endplateLow grade;
9/76 (11.8%)
High grade; 6/76 (7.9%)Most spinal pathology considered
Excluded patients with previous lumbar surgery history, neurological lesions, peripheral neuropathy and other diseases entitiesX-ray imaging VAS, ODI, and JOA Abbreviations: ALIF, anterior lumbar interbody fusion; ASD, adjacent segment disease; BMI, body mass index; CT, computed tomography; JOA, Japanese Orthopaedic Association ; LLIF, lateral lumbar interbody fusion; ODI, Oswestry Disability Index; OLIF, oblique lumbar interbody fusion; PEEK, polyetheretherketone; PLIF, posterior lumbar interbody fusion; SF-12, 12-Item Short Form Health Survey; TLIF, transverse lumbar interbody fusion; VAS, visual analog scale; XLIF, extreme lateral interbody fusion.
↵a Subsidence reported by levels.
↵b Less than 80% follow-up.
Variable ALIF LLIF LLIF-P OLIF-P PLIF-P TLIF-P Pathology Adjacent segment disease - 139 - - 139 - Spondylolisthesis 118 - 235,38 - - 235,38 No specific pathology 526–30 109,10,12,23,35–40 610,31–33,36,37 713,43–48 427,30,49,50 125,7,11,14,26,27,44,47,51–54 Levels Single 127 - 336–38 444,47,48 227,49 105,7,11,29,31,46,49,52,53,55 Multiple and single 218,26 119,10,12,23,33,34,39–42,55 510,31–33,35 413,43,45,46 239,50 414,26,35,53 Unspecified 328–30 - - - 130 - Total number of articles reviewed 6 11 8 7 5 14 Abbreviations: ALIF, anterior lumbar interbody fusion; LLIF, lateral lumbar interbody fusion; LLIF-P, LLIF with posterior fixation; OLIF-P, oblique lumbar interbody fusion with posterior fixation; PLIF-P, posterior lumbar interbody fusion with posterior fixation; TLIF-P, transverse lumbar interbody fusion with posterior fixation.
Authors (Year) Pain Score Disease-Specific Function Overall Quality of Life Other Power Analysis Marchi et al (2013)12 Significant correlation
Higher-grade subsidence led to higher axial back pain (P = 0.029)N/A N/A N/A N/A Lequin et al (2014)57 No significant correlation
VAS: r = −0.2, P = 0.459N/A N/A N/A N/A Malham et al (2015)33 N/A N/A N/A No significant correlation
MCID criteria (P > 0.05)Underpowered Oh et al (2017)50 No significant correlation
VAS: r = 0.017, P = 0.874No significant correlation
ODI: r = −0.006, P = 0.956No significant correlation
SF-36: r = 0.015, P = 0.886N/A N/A Rao et al (2017)29 No significant correlation
VAS: P = 0.36No significant correlation
ODI: P = 0.55No significant correlation
SF-12 mental component (P = 0.64)
SF-12 physical component (P = 0.69)N/A N/A Chang et al (2019)45 N/A Significant correlation
Subsidence led to higher ODI: 45.4–33.8, P = 0.02Significant correlation
Subsidence led to lower SF-36: 33.6–41.4, P = 0.01N/A N/A Abbreviations: MCID, minimum clinically important difference; ODI, Oswestry Disability Index; SF-36, Short Form 36 Health Survey Questionnaire; VAS, visual analog scale.
Authors (Year) Nonunion Revision Surgery Other Nemani et al (2014)56 N/A 4/12 (33.3%) patients requiring revision surgery was due to subsidence N/A Tempel et al (2018)34 N/A Significant correlation between revision surgery and high-grade subsidence:
(P < 0.05; OR: 12.95% CI: 1.29–13.6)
−6.1% (18/296) required revision surgery due to subsidence (all patients with high-grade subsidence)N/A Chen et al (2019)23 No correlation between subsidence and fusion: P = 0.242 N/A N/A Lin et al (2019)13 Significant correlation Subsidence was a risk of nonunion
OR: 17.24; 95% CI: 1.67–178.09N/A Significant correlation Subsidence was a risk of positive cyst
OR: 8.37; 95% CI: 2.71–25.89Park et al (2019)53 Fusion rate: No cage migration = 801/825 (97.1%)
Cage migration with no subsidence = 11/20 (55%)
Cage migration with subsidence = 15/36 (41.7%)
N/A Significantly higher rate of screw loosening for the group with cage migration with subsidence compared with group with cage migration with no subsidence Cage migration with no subsidence = 2/20 (10%)
Cage migration with subsidence = 22/36 (61.1%)
- Table 6
Occurrence of subsidence per LIF method considering 25–50% or >2 mm migration of the cage in the endplate.
LIF Surgical Approach Subsidence Occurrence No. of Studies Minimum Maximum ALIF 6% (3/50)26 23.1% (3/13)30 6 LLIF 8.7% (29/335)34,41 (26/297)34,41 39.6% (38/96)42 11 LLIF with posterior fixation 3.3% (1/30)35 20.7% (6/29)38 8 OLIF with posterior fixation 4.4% (6/137)43 36.9% (62/168)45 7 PLIF with posterior fixation 7.4% (2/27)30 31.8% (11/41)39 5 TLIF with posterior fixation 0% (0/40)26 51.2% (21/41)38 14 Abbreviations: ALIF, anterior lumbar interbody fusion; LIF, lumbar interbody fusion; LLIF, lateral lumbar interbody fusion ; OLIF, oblique lumbar interbody fusion; PLIF, posterior lumbar interbody fusion; TLIF, transverse lumbar interbody fusion.
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