Elsevier

The Spine Journal

Volume 3, Issue 4, July–August 2003, Pages 301-309
The Spine Journal

Contemporary concepts in spine care
Intervertebral cages for degenerative spinal diseases

https://doi.org/10.1016/S1529-9430(03)00004-4Get rights and content

Abstract

Interbody fusion techniques have been used for many years for the treatment of a variety of lumbar spine diagnoses. Part of the interest in increasing methods of interbody fusion has stemmed from concern that posterior fusion alone may allow micro-motion, which may generate pain in a ruptured or degenerated disc. Stabilization of the anterior segment led to the development of interbody fusion cages. These devices were designed to stabilize the spine while bony ingrowth from the vertebrae to the bone graft occurred. There are a variety of techniques for cage insertion, including open and laparoscopic techniques anteriorly, and open posterior approach. A lateral approach for cage placement has also been reported. The purpose of this paper is to present a review of the literature on lumbar intervertebral fusion performed using interbody cages. The reported results for these procedures vary, but in general the majority of patients have had favorable results. The complications are similar to those encountered with traditional interbody fusion procedures using bone grafts. There is a learning curve associated with the procedures, particularly with the laparoscopic techniques. Appropriate training for the spine surgeon as well as the access surgeon is important. There is a great deal of disparity in reports on using the cages as stand-alone devices as well as on laparoscopic approaches. Overall, the use of interbody cages for fusion appears to be a viable treatment, yielding good results. Fusion cages appear to have a role in spine care; however, as with any procedure, patient selection and proper training of the surgeon are critical.

Introduction

One of the major objectives of spinal fusion is to relieve pain arising from spinal structures by removing potentially pain-generating disc tissue and stabilizing one or more motion segments. Various methods of posterior lumbar fusion (PLF) have long been used for this purpose. Interbody fusion procedures became more widely used for their stabilizing effect on the spine segment and as the role of the lumbar disc as a pain generator became better appreciated. The primary concept behind lumbar interbody fusion is that by removing all or most of the disc and stabilizing the operated segment with bone graft, the primary pain generator is removed. Stabilizing the segment should then eliminate mechanical stimulation that may provoke symptoms and may avoid future problems associated with collapse of an unsupported space. In a biomechanical study, interbody fusion was found to be stiffer than posterior lumbar fusion [1]. In addition; the surface area between the host bone and the graft is much greater with interbody fusion than with intertransverse process fusion.

Many interbody fusion methods have been described in the literature, which have included various surgical approaches to the disc as well as using different types of graft material. In recent years, several types of fusion cages have been developed. All are designed to be packed with graft, and all have holes in the inferior and superior surfaces to allow bone to grow from the vertebral bodies through the cage and unite with the bone inside the cage. Currently, the most commonly used cages are threaded metal cylinders. Also available are rectangular design cages and plates with struts to adjust the height and angle between the upper and lower plates. Cages are available in a variety of sizes to accommodate variation in individual patient anatomy. The purpose of this paper is to provide a review of the literature related to using fusion cages in lumbar interbody fusion procedures.

Section snippets

Historical background of interbody fusion

Burns [2] of Great Britain reported the first lumbar interbody fusion in 1933. From an anterior approach (anterior lumbar interbody fusion, ie, ALIF), he used an autogenous tibial peg to treat an adolescent with spondylolisthesis. Posterior lumbar interbody fusion (PLIF) was first performed in the early 1940s 3, 4, 5. These early posterior procedures involved packing bone fragments into the disc space after discectomy. Through the years, various techniques and grafts have been used for

Anatomy/pathophysiology

The two primary purposes of interbody fusion are to relieve pain and stabilize the symptomatic spine segment. In cases of disc-related pain, the symptom-related tissue is removed. However, the removal of this tissue may cause the disc space to collapse with a concomitant narrowing of the foramen and related changes of the facet joints, causing nerve root compression. By filling the disc space with bone graft, the disc space height is reestablished. This may also increase the height of the

Anterior versus posterior approach to interbody fusion

Several cages are designed to be implanted into the disc space using either the anterior or posterior approach. Based on the review of the literature, there is no general preference for the approach to be used. The decision on the type of approach should be made based on several factors, such as the pathology present, spinal anatomy, patient's history of prior surgery (either approach may be more difficult if there is significant scarring from prior surgeries), vascular anatomy (and conditions

Indications and operative considerations

The general indications for fusion cages are basically the same as for traditional interbody fusion: symptomatic disc disruption and/or symptomatic disc degeneration, postlaminectomy syndrome with/without recurrent disc herniation, pseudarthrosis, low-grade spondylolisthesis, instability and, in some cases, degenerative scoliosis. As with other spine surgeries, in the absence of progressive neurologic problems, patients should have failed an aggressive attempt of nonoperative care before

Discussion

Fusion cages are now commonly used for the treatment of low back pain with or without related extremity pain. With regard to approach (anterior vs. posterior) or open versus laparoscopic placement, the decision should be at the discretion of the surgeon and made based on the patient's anatomy, history, pathology present and the surgeon's training and experience.

With regard to using the cages as stand-alone devices, the reported results vary. Some authors report large series with no supplemental

Bone growth stimulation

There has been no clinical investigation on the effect of bone growth stimulation on fusion involving cages. Toth et al. [61] reported that direct current stimulation increased the fusion rate in sheep in a study involving titanium threaded fusion cages packed with autograft.

Bone graft substitutes

Studies in animal models have demonstrated good fusion results using recombinant human bone morphogenetic protein-2 (rhBMP-2) 62, 63, local gene therapy [64] and recombinant human osteogenic protein-1 (rhOP-1) [65]. In

Conclusions with key points

The results of this review support that fusion cages can be used with a complication rate comparable to traditional bone graft in interbody fusions. Unfortunately, as with many issues in spine surgery, there is a need for large-scale randomized studies to better delineate the role of fusion cages. Such studies are needed to address the use of cages as stand-alone devices versus their use combined with posterior fixation as well as the use of metallic cages versus allograft cages, versus

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    The board of the North American Spine Society (NASS) has reviewed this Contemporary Concepts review article. As such, it represents the current position on the state of knowledge of the above subject in spine care. Alexander Vaccaro, MD, edits this series. Before entering the review process for The Spine Journal, the authors were assisted by members of the NASS Committee on Contemporary Concepts, Alexander Vaccaro, MD, Chair. FDA device/drug status: not applicable. Author SLB acknowledges a former consultant relationship with US Surgical. No financial support has been received related to the preparation of this manuscript.

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