Article Figures & Data
Figures
- Figure 1
Radiographic images of 2-level lumbar fusion. (A1 and A2) Postoperative anteroposterior and lateral x-ray images of posterior lumbar interbody fusion (PLIF). (B1 and B2) Postoperative anteroposterior and lateral x-ray images of posterior lumbar fusion (PLF). (C1 and C2) Postoperative anteroposterior and lateral x-ray images of hybrid surgery combining distal PLIF with proximal PLF.
- Figure 2
Changes in patient-reported scores and radiographic parameters at different follow-up time points (3, 6, 12, 36, and 60 months) after surgery. Abbreviations: JOA = Japanese Orthopedic Association; ODI = Oswestry Disability Index; PLF = posterior lumbar fusion; PLIF = posterior lumbar interbody fusion; SF-36 = 36-item Short Form Health Survey; VAS = visual analog scale.
- Figure 3
Imaging of adjacent segment degeneration development in hybrid surgery 54 months postoperatively. (A and B) Anteroposterior and lateral x-ray images of hybrid surgery at L3–L5. (C–E) Computed tomography images showing disc protrusion and spinal stenosis at the adjacent levels L5–S1.
- Figure 4
Imaging of posterior cage migration and subsidence. (A) Lateral x-ray of a patient showing proper cage position at L3/4, 3 months after surgery. (B) Mild subsidence of the L3/4 cage observed at 36 months postoperatively. (C) Significant subsidence of the L3/4 cage observed at 60 months postoperatively.
Tables
Criteria Inclusion Patients with degenerative lumbar disease, including degenerative disc herniation, degenerative lumbar stenosis, and degenerative lumbar spondylolisthesis Preoperative radiographs, including plain radiographs, computed tomography, and magnetic resonance imaging, were complete. Symptoms for at least for 6 months and refractory to conservative therapy Clinical signs consistent with radiographs Availability of pre- and postoperative radiographs and medical records History of previous lumbar surgery or infection Exclusion Patients with severe sagittal imbalance Patients who underwent interbody fusion using a stand-alone cage or expandable cage Patients underwent anterior, extreme lateral, or transforaminal interbody fusion Patients with severe osteoporosis, rheumatoid arthritis, or destructive spondyloarthropathy Patients with less than 48-month follow-up Variable PLIF group
(n = 122)PLF group
(n = 126)Hybrid group
(n = 130)Statistic P Age, y 58 ± 9 60 ± 8 59 ± 10 0.279 0.757 Gender 4.575 0.101 Men 61 (50%) 42 (33.3%) 39(30%) Women 61 (50%) 84 (66.7%) 91(70%) BMI (kg/m2) 25.3 ± 3.8 24.8 ± 3.0 25.9 ± 3.6 1.470 0.233 Primary diagnosis 6.215 0.184 Lumbar spondylolisthesis 15 (11.9%) 34 (26.7%) 37 (28.3%) Lumbar stenosis 61 (50%) 45 (35.6%) 61 (46.7%) Lumbar disc herniation 46 (38.1%) 47 (37.8%) 33 (25.0%) Pfirrmann’s classification of the upper adjacent segment 6.698 0.584 I 29 (23.8%) 30 (24.4%) 28 (21.7%) II 26 (21.4%) 47 (37.8%) 50 (38.3%) III 46 (38.1%) 27 (22.2%) 28 (21.7%) IV 14 (11.9%) 17 (13.3%) 15 (11.7%) V 7 (4.8%) 5 (2.2%) 9 (6.7%) Pfirrmann’s classification of lower adjacent segment 8.218 0.412 I 17 (14.3%) 20 (15.6%) 33 (25%) II 46 (38.1%) 59 (46.7%) 50 (38.3%) III 26 (21.4%) 22 (17.8%) 33 (25%) IV 23 (19%) 11 (8.9%) 11 (8.3%) V 10 (7.1%) 14 (11.1%) 4 (3.3%) Affected levels 0.234 0.890 3 levels 70 (57.1%) 78 (62.2%) 78 (60%) 4 levels 52 (42.9%) 48 (37.8%) 52 (40%) Duration of follow-up (y) 6.2 ± 1.0 6.4 ± 1.2 6.1 ± 1.1 2.467 0.088 Functional scores ODI 71.9 ± 7.5 71.9 ± 3.9 73.7 ± 4.7 2.111 0.124 JOA 11.2 ± 2.5 11.4 ± 2.9 11.2 ± 2.8 0.116 0.891 VAS (low back) 4.9 ± 1.0 5.1 ± 1.1 5.2 ± 1.2 1.559 0.213 VAS (low limbs) 6.5 ± 1.1 6.8 ± 1.0 6.5 ± 1.1 1.251 0.289 SF-36 PCS (%) 22.0 ± 5.7 23.0 ± 6.2 21.1 ± 5.8 1.650 0.195 SF-36 MCS (%) 32.4 ± 6.0 33.0 ± 6.2 31.0 ± 5.6 1.960 0.114 Abbreviations: BMI, body mass index; JOA, Japanese Orthopedic Association; MCS, Mental Component Score; ODI, Oswestry Disability Index; PCS, Physical Component Score; PLF, posterior lumbar fusion; PLIF, posterior lumbar interbody fusion; SF-36, 36-item Short Form Health Survey; VAS, visual analog scale.
Note: Data presented as mean ± SD or n (%).
- Table 3
Repeated-measures ANOVA for comparison of clinical outcomes at each follow-up time.
Variables Groups Post 3 mo Post 6 mo Post 12 mo Post 36 mo Post 60 mo Statistic 1 a P1a Statistic 2b P2b VAS-back PLIF 3.1 ± 0.9a 1.8 ± 0.9 b,e 1.3 ± 0.8 c,d 1.4 ± 1.0 c,d 1.6 ± 1.9 b,e 0.685 0.690 117.414 <0.001 PLF 3.1 ± 0.9a 1.9 ± 0.8 b,e 1.2 ± 0.8 c,d 1.1 ± 1.0 c,d 1.7 ± 1.1 b,e Hybrid 3.1 ± 1.0a 1.8 ± 0.9 b,e 1.3 ± 0.8 c,d 1.1 ± 1.0 c,d 1.6 ± 1.1 b,e VAS-leg PLIF 2.5 ± 1.1a 0.7 ± 0.7 b,d,e 0.7 ± 0.8c 1.1 ± 1.0 b,d,e 1.5 ± 1.1 b,d,e 0.648 0.722 94.174 <0.001 PLF 2.7 ± 1.1a 1.1 ± 0.6 b,d,e 0.8 ± 0.8c 1.2 ± 1.0 b,d,e 1.3 ± 1.0 b,d,e Hybrid 2.5 ± 1.08a 1.3 ± 0.7 b,d,e 0.7 ± 0.8c 1.1 ± 1.0 b,d,e 1.5 ± 1.1 b,d,e JOA PLIF 15.3 ± 3.0a 18.9 ± 3.3b 22.4 ± 3.3 c,e 22.3 ± 3.5d 22.1 ± 3.6 d,e 2.167 0.047 389.274 <0.001 PLFc 15.0 ± 2.6a 18.2 ± 2.5b 21.4 ± 2.2 c,e 22.0 ± 2.71d 21.7 ± 2.9 d,e Hybridc 16.0 ± 2.5a 18.8 ± 2.7b 21.9 ± 2.3 c,e 23.3 ± 1.99d 23.5 ± 2.6 d,e ODI PLIFc 56.3 ± 8.3a 46.1 ± 7.2b 35.6 ± 5.8c 28.9 ± 5.21 d,e 28.9 ± 7.0e 2.826 0.006 939.294 <0.001 PLF 55.6 ± 6.6a 44.1 ± 5.0b 33.4 ± 5.9c 27.6 ± 5.8 d,e 28.4 ± 5.5e Hybridc 53.7 ± 5.34a 44.5 ± 5.3b 34.9 ± 5.2c 25.5 ± 4.8 d,e 24.2 ± 4.22e SF-36d PLIF 37.3 ± 4.8a 52.6 ± 5.8b 63.4 ± 4.5c 70.6 ± 6.9d 73.0 ± 6.2e 3.589 <0.001 1020 <0.001 PLF 38.4 ± 7.1a 51.8 ± 6.5b 64.5 ± 6.8c 71.4 ± 5.7d 74.1 ± 6.0e Hybrid 40.1 ± 7a 50.3 ± 6.65b 61.3 ± 8.1c 72.8 ± 6.0d 76.5 ± 6.5e Cobb PLIF 49.7 ± 5.1a 50.5 ± 5.3 a,b,c,d,e 51.3 ± 4.6c 47.1 ± 7.8 a,d 43.3 ± 7.2e 3.594 <0.001 18.176 <0.001 PLF 48.7 ± 6.9a 49.9 ± 6.1 a,b,c,d,e 50.7 ± 5.6c 48.5 ± 6.8 a,d 45.4 ± 6.2e Hybrid 47.7 ± 5.1a 48.8 ± 6.7 a,b,c,d,e 50.5 ± 7.8c 49.6 ± 8.4 a,d 48.1 ± 7.0e Abbreviations: ANOVA, analysis of variance; JOA, Japanese Orthopedic Association; ODI, Oswestry Disability Index; SF-36, 36-item Short Form Health Survey; VAS, visual analog scale.
Note: Data presented as mean ± SD. The use of superscripts a, b, c, d, and e in the data cells denotes pairwise comparisons. If the superscript letters between 2 groups are different, it indicates a significant difference between the groups. For example, when comparing the mean ODI scores at 12, 36, and 60 months post-surgery in the hybrid group, the mean at 12 months post-surgery is marked with “c,” the mean at 36 months post-surgery is marked with “d,e,” and the mean at 60 months post-surgery is marked with “e.” This indicates that the mean ODI score at 12 months post-surgery is significantly different from the means at 36 and 60 months post-surgery, while there is no significant statistical difference between the means at 36 and 60 months post-surgery.
↵a Measure time.
↵b Interaction analysis between group and measure time.
↵c Mean statistical significance between groups.
↵d The data satisfy Mauchly’s test of sphericity.
Variables PLIF group
(n = 122)PLF group
(n = 126)Hybrid group
(n = 130)P Intraoperative complications 18 (15) 8 (6.6) 13 (9.8) 0.050 Dural tear 13 (10.6) a 4 (3.3) b 8 (6.3) a,b 0.035 Nerve root injury 5 (4.4) 4 (3.3) 5 (3.5) 0.863 Adverse events 29 (24.4) a 21 (16.4) a,b 16 (12.5) b 0.022 Sensory deficiency 6 (5) 7 (5.9) 5 (3.5) 0.612 Screw loosening 3 (2.5) 2 (1.3) 2 (1.4) 0.604 Cage subsidence 8 (6.9) NA 4 (2.8) 0.117 Cage retropulsion 5 (4.4) NA 2 (1.4) 0.179 Others a 7 (5.6) 12 (9.2) 5 (3.5) 0.114 5-year ASDeg-multilevel 56/135 (42)a 52/141 (37)a,b 40/138 (29)c 0.044 Upper 37/92 (40.2) 34/94 (36) 22/84 (27.8) 0.104 Lower 20/43 (46.5) 18/47 (38.3) 18/54 (33.3) 0.430 5-year ASDis-multilevel 16/135 (12.3) 16/141 (9.9) 10/138 (7.6) 0.338 Upper 10/92 (10.7) 9/94 (9.7) 6/84 (6.9) 0.577 Lower 7/43 (16.3) 5/47 (10.6) 5/54 (9.3) 0.581 Abbreviations: ASDeg, adjacent segment degeneration; ASDis, adjacent segment disease; NA, not applicable; PLF, posterior lumbar fusion; PLIF, posterior lumbar interbody fusion.
Note: Data are presented as n (%). The use of superscripts a, b, and c in the data cells denotes pairwise comparisons. If the superscripts are different, it indicates a significant difference between the groups. See Table 3 for additional explanation.
↵a Wound infection, rod broken, screw broken, and pseudarthrosis.
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