Elsevier

World Neurosurgery

Volume 118, October 2018, Pages 21-31
World Neurosurgery

Literature Review
Lumbar Lordosis Correction with Interbody Fusion: Systematic Literature Review and Analysis

https://doi.org/10.1016/j.wneu.2018.06.216Get rights and content

Highlights

  • Evidence-based average degrees of correction of lumbar lordosis for 3 main lumbar interbody fusion techniques are shown.

  • ALIF, L-LIF, and TLIF can all be safely used to achieve correction of lumbar lordosis.

  • Randomized, controlled trials are needed to directly compare the effectiveness of ALIF, L-LIF, and TLIF.

Objective

The goal of this study was to conduct an evidence-based quantitative assessment of the correction of lumbar lordosis achieved by each of the 3 principal lumbar interbody fusion techniques: anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (L-LIF), and transforaminal lumbar interbody fusion (TLIF).

Methods

A systematic review of the literature was conducted to identify studies containing degrees of correction of lumbar lordosis achieved by ALIF, L-LIF, and TLIF as shown on standing lumbar radiography at least 6 weeks after surgical intervention. Pooled and Forest plot analyses were performed for the studies that met inclusion criteria.

Results

For ALIF, 21 studies were identified with mean correction 4.67° (standard deviation [SD] ± 4.24) and median correction 5.20°. Fifteen studies were identified that met criteria for Forest plot analysis with mean correction 4.90° (standard error of the mean [SEM] ± 0.40). For L-LIF, 17 studies were identified with mean correction 4.47° (SD ± 4.80) and median correction 4.00°. Nine studies were identified that met criteria for Forest plot analysis with mean correction 2.91° (SEM ± 0.56). For TLIF, 31 studies were identified with mean correction 3.89° (SD ± 4.33) and median correction 3.50°. Twenty-five studies were identified that met criteria for Forest plot analysis with mean correction 5.33° (SEM ± 0.27).

Conclusions

We present the current evidence-based mean correction for each of the 3 principal lumbar interbody fusion techniques based on standing radiographic data.

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

References (67)

  • C.J. Sparrey et al.

    Etiology of lumbar lordosis and its pathophysiology: a review of the evolution of lumbar lordosis, and the mechanics and biology of lumbar degeneration

    Neurosurg Focus

    (2014)
  • R.J. Mobbs et al.

    Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF

    J Spine Surg

    (2015)
  • F.J. Schwab et al.

    Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis

    Spine (Phila Pa 1976)

    (2013)
  • K. Slim et al.

    Methodological index for non-randomized studies (minors): development and validation of a new instrument

    ANZ J Surg

    (2003)
  • J.N. Sembrano et al.

    Radiographic comparison of lateral lumbar interbody fusion versus traditional fusion approaches: analysis of sagittal contour change

    Int J Spine Surg

    (2015)
  • P.C. Hsieh et al.

    Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance

    J Neurosurg Spine

    (2007)
  • I.G. Dorward et al.

    Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis

    Spine (Phila Pa 1976)

    (2013)
  • J.K. Lim et al.

    Radiographic results of minimally invasive (MIS) lumbar interbody fusion (LIF) compared with conventional lumbar interbody fusion

    Korean J Spine

    (2013)
  • R.G. Watkins et al.

    Sagittal alignment after lumbar interbody fusion: comparing anterior, lateral, and transforaminal approaches

    J Spinal Disord Tech

    (2014)
  • J.S. Kim et al.

    Mini-transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion augmented by percutaneous pedicle screw fixation: a comparison of surgical outcomes in adult low-grade isthmic spondylolisthesis

    J Spinal Disord Tech

    (2009)
  • C.J. Siepe et al.

    Anterior stand-alone fusion revisited: a prospective clinical, X-ray and CT investigation

    Eur Spine J

    (2015)
  • K.L. Jackson et al.

    Anterior lumbar interbody fusion: two-year results with a modular interbody device

    Asian Spine J

    (2014)
  • C.H. Kim et al.

    A change in lumbar sagittal alignment after single-level anterior lumbar interbody fusion for lumbar degenerative spondylolisthesis with normal sagittal balance

    Clin Spine Surg

    (2017)
  • K.C. Choi et al.

    Does pre-existing L5-S1 degeneration affect outcomes after isolated L4-5 fusion for spondylolisthesis?

    J Orthop Surg Res

    (2015)
  • S.H. Tang et al.

    Does disc space height of fused segment affect adjacent disc degeneration in anterior lumbar interbody fusion? A radiological study

    Iran Red Crescent Med J

    (2012)
  • J.R. Dimar et al.

    Lumbar lordosis restoration following single-level instrumented fusion comparing 4 commonly used techniques

    Orthopedics

    (2011)
  • D.Y. Lee et al.

    Two-level anterior lumbar interbody fusion with percutaneous pedicle screw fixation: a minimum 3-year follow-up study

    Neurol Med Chir (Tokyo)

    (2010)
  • K.H. Kim et al.

    Anterior bone cement augmentation in anterior lumbar interbody fusion and percutaneous pedicle screw fixation in patients with osteoporosis

    J Neurosurg Spine

    (2010)
  • D.G. Crandall et al.

    Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes

    Spine (Phila Pa 1976)

    (2009)
  • J.H. Min et al.

    Comparison of anterior- and posterior-approach instrumented lumbar interbody fusion for spondylolisthesis

    J Neurosurg Spine

    (2007)
  • S.H. Lee et al.

    Revision surgery of the lumbar spine: anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation

    J Neurosurg Spine

    (2006)
  • D.J. Blizzard et al.

    Sagittal balance correction in lateral interbody fusion for degenerative scoliosis

    Int J Spine Surg

    (2016)
  • J.C. Manwaring et al.

    Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study

    J Neurosurg Spine

    (2014)
  • Cited by (43)

    • Application of offset Dingo instruments in Anterior to Psoas (ATP)/Oblique Lumbar Interbody Fusion (OLIF) procedure: A retrospective study of 80 patients

      2022, Neurochirurgie
      Citation 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.

    View all citing articles on Scopus

    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.

    View full text