Literature ReviewLumbar Lordosis Correction with Interbody Fusion: Systematic Literature Review and Analysis
Introduction
The maintenance and correction of sagittal balance has become a popular topic within the spine surgical literature principally because of its direct impact on outcomes and quality of life. Within the thoracolumbar surgical literature, there is hardly a single variable so powerfully associated with positive surgical outcomes.1 However, at the time of surgery, it is easy to overlook the potentially large impact that disturbing a patient's sagittal balance may have on their overall outcome. Biomechanical studies have shown that approximately 85% of lumbar lordosis is given by the L3-S1 segment, and it is no coincidence that most surgeries performed for degenerative lumbar disease occur at these levels.2 The 3 most common lumbar interbody techniques are anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (L-LIF, extreme L-LIF, and direct L-LIF), and transforaminal lumbar interbody fusion (TLIF).
There exists a large body of data on the impact of various standard surgical procedures on sagittal balance, but there is no resource that has systematically characterized the evidence-based outcomes. Canonically, it is generally stated that ALIF offers the greatest degrees of correction, followed by L-LIF, then TLIF.3
The purpose of this study is to analyze the current outcomes data on lumbar lordosis correction as it relates to each of the principal interbody fusion techniques typically used for the lumbar spine. Although many surgeons cite personal experience and mentors' experience in selecting the procedure for each patient, there is a body of literature that should guide these choices.
One relationship that seems to greatly affect outcomes regarding the lumbar spine is that between pelvic incidence and lumbar lordosis.4 Pelvic incidence is considered as a fixed physiologic value for an individual that is defined by the angle between the line perpendicular to the sacral plate and the line connecting the midpoint of the sacral plate to the bicoxofemoral axis. Lumbar lordosis is the Cobb angle generated between the line parallel to the superior end plate of the L1 vertebral body and the S1 vertebral body. If the difference between these 2 values is >10°, this so-called mismatch is predictive of unstable sagittal balance, causing continued pain and likely requiring surgical intervention. Of the 2 values, only lumbar lordosis is considered surgically modifiable, and hence the focus of this study.
Section snippets
Study Selection
A systematic review of the literature was conducted using the search terms “sagittal balance,” “lumbar lordosis,” “lumbar interbody fusion,” “anterior lumbar interbody fusion,” “lateral lumbar interbody fusion,” “extreme lateral lumbar interbody fusion,” “direct lateral lumbar interbody fusion,” and “transforaminal lumbar interbody fusion” (PubMed, Cochrane, and Embase). A total of 1145 publications were identified for initial review.
The primary outcome for this study was degrees of correction
ALIF
ALIF is a well-described surgical approach that is used primarily at L4-L5 and L5-S1 based on vascular constraints posed by the common iliac artery and vein. It includes cutting the anterior longitudinal ligament, performing a large discectomy, and placing an interbody graft. Various graft angulations can be used, and often, the fusion is backed up with posterior instrumentation (pedicle screws and rods).
Twenty-one studies were identified with preoperative and postoperative standing radiography
Discussion
Many variables influence the choice of an interbody fusion procedure for the individual patient. These variables can include affected levels, goals of surgery (decompression of neural elements vs. deformity correction), previous surgery and existing hardware, patient age and comorbidities, and surgeon experience. However, the goal of surgery is a positive outcome, and thus the preservation or restoration of sagittal balance. The results of this study suggest that all 3 interbody fusion
Conclusions
The ideal lumbar interbody fusion technique is debated by spine surgeons, with anecdotal evidence and personal experience often driving clinical decision making. Randomized controlled trials and surgical registries are needed to directly compare the effectiveness of ALIF, L-LIF, and TLIF in correction of lumbar lordosis. Although there are many potential biases, our study shows the evidence-based average degrees of correction of lumbar lordosis for each of the 3 main lumbar interbody fusion
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Minimally Invasive Transforaminal Lumbar Interbody Fusion: Strategies for Creating Lordosis with a Posterior Approach
2023, Neurosurgery Clinics of North AmericaDeformity correction techniques in adult spinal deformity
2023, Seminars in Spine SurgeryApplication of offset Dingo instruments in Anterior to Psoas (ATP)/Oblique Lumbar Interbody Fusion (OLIF) procedure: A retrospective study of 80 patients
2022, NeurochirurgieCitation Excerpt :OLIF with the anterior to psoas (ATP) approach is regarded as a solution to the approach-related disadvantages of anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF), since it utilizes the natural anatomical space between the left psoas muscle and the aorta/inferior vena cava (IVC) to access the targeted intervertebral disc [2–5]. A large surface area interbody cage can be inserted into the intervertebral space through the lateral approach, which can improve the sagittal alignment and restore the disc height while indirectly decompressing the neurological elements [5–8]. Therefore, OLIF is a minimally invasive lumbar fusion procedure that does not cause damage to the paraspinal muscles and posterior bony structures compared to traditional posterior or posterolateral fusion.
Conflict of interest statement: The authors declare no direct potential conflicts of interest with respect to the research, authorship, and/or publication of this article. S.C. is a consultant for Medtronic, Globus, and Zimmer-Biomet and holds unrelated research grants from Zimmer-Biomet and the National Institutes of Health (NIH). J.C. is a consultant for Zimmer-Biomet. The other authors have no stated direct or indirect conflicts of interest.