Elsevier

World Neurosurgery

Volume 115, July 2018, Pages e659-e663
World Neurosurgery

Original Article
Intraoperative and Postoperative Segmental Lordosis Mismatch: Analysis of 3 Fusion Techniques

https://doi.org/10.1016/j.wneu.2018.04.126Get rights and content

Highlights

  • Lumbar lordosis is fundamental for patients' quality of life, and its restoration or improvement is a major target in spinal surgery.

  • Despite all the efforts, spine surgeons often fail to achieve planned lumbar lordosis.

  • Percutaneous posterolateral instrumentation (pPLI) with extreme lateral interbody fusion (XLIF) is associated with smaller mismatch between intraoperative and postoperative lumbar lordosis.

Objective

This study aimed to quantify the discrepancy between intraoperative and postoperative segmental lordosis in patients operated on for lumbar degenerative diseases, with 3 different fixation techniques: open posterolateral instrumentation alone (PLI) or in association with lumbar interbody cages (transforaminal lumbar interbody fusion [TLIF] or extreme lateral interbody fusion [XLIF]).

Methods

We retrospectively reviewed all adult patients affected by single-segment degenerative spondylotic disease who underwent PLI alone or percutaneous posterolateral instrumentation (pPLI) in association with TLIF or XLIF between April 2015 and December 2017 at our institution. Group I included patients who underwent PLI with transpedicular screws and rods, interlaminar bilateral decompression, and posterolateral fusion with autologous bone chips. Group II included patients treated with pPLI + TLIF using a complete unilateral arthrectomy. Group III included patients operated on with minimally invasive retroperitoneal pPLI + XLIF.

Results

No major complications were reported. The mean segmental loss of lordosis values ranged from 9.17% to 12.28% in Group I, from 6.31%–9.43% in Group II, and from 3.05%–4.71% in Group III. The statistical analysis revealed that pPLI + XLIF maintained a higher segmental lordosis than PLI and pPLI +TLIF in each operated segment (P < 0.05). pPLI + TLIF was more effective than PLI in reducing the loss of lordosis at L4-L5 and at L5-S1 (P < 0.05) but not at L3-L4 (P = 0.12).

Conclusions

The documented mismatch between the preoperative and postoperative lumbar lordosis might affect the clinical outcome. Its relevance depends on the surgical technique used at the single level.

Introduction

Lumbar lordosis (LL) is defined by the sum of single segmental angles between L1 and S1 on lateral radiographs. LL and sagittal spinal alignment strongly correlate with a patient's quality of life, and most patients affected by lumbar degenerative disorders have a significant loss of lordosis (LoL) at either the affected segment or globally at the lumbar spine.1, 2, 3, 4 Surgical restoration or improvement of LL is a major target in spinal surgery. Despite ongoing efforts to develop more precise surgical plans, surgical procedures fail to achieve the planned LL in approximately one-third of the cases5 and the rate of postoperative incomplete sagittal correction is as high as 50%.6

Many studies show that there is an unavoidable difference between the observed intraoperative LL correction and the actual LL measured postoperatively, but this important bias has not been investigated in detail. To confirm and measure this difference, we conducted a retrospective study that analyzed the intraoperative and postoperative single-segment lordosis angles in patients who underwent single-level arthrodesis for lumbar degenerative diseases.

Section snippets

Materials and Methods

We retrospectively reviewed all adult patients affected by single-segment degenerative disease who underwent open posterolateral instrumentation (PLI) alone or percutaneous posterolateral instrumentation (pPLI) in association with lumbar interbody cages (transforaminal lumbar interbody fusion [TLIF] or XLIF) between December 2015 and April 2017 at our institution. The exclusion criteria were previous lumbar surgery; body mass index ≥30 kg/m2; scoliosis; osteoporosis; rheumatoid arthritis;

Results

The study included 93 patients, 59 women and 34 men, with an average age (range) of 57 (43–77) years and an average (range) body mass index of 23 (18–29). Group I had 26 patients (28%), Group II had 43 patients (46%), and Group III had 24 patients (26%) based on the surgical technique used for lumbar fixation. No major intraoperative or perioperative complications (such as death, persistent neurologic deficit) were reported in our series. We reported 2 cases of superficial wound infection (1 in

Discussion

In recent years, curvature of the spine (both static and dynamic), spinopelvic characteristics, and orthostatic balance have been quantified and analyzed in asymptomatic populations and in patients affected by low back pain due to degenerative diseases.8, 9, 10, 11, 12 Sagittal balance strongly correlates with quality of life, and its correction, rather than the coronal balance, is the best positive prognostic factor for clinical outcome.4, 13, 14 According to Dimar et al,15 in cases with

Conclusion

Correction of LL remains a major challenge in spinal surgery. The well-documented mismatch between the preoperatively planned SL correction and final result impacts the radiologic outcome and depends on the chosen surgical fixation technique and on the vertebral segment involved. In this study, the pPLI + XLIF fixation technique showed the smallest LoL, while PLI alone showed the greatest difference between intraoperative and postoperative measurement. Further studies are needed to better

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    Conflict of interest statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors, and the authors have no conflicts of interest.

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