Effect of one- or two-level posterior lumbar interbody fusion on global sagittal balance

doi:10.1016/j.spinee.2017.05.029

The Spine Journal

Volume 17, Issue 12, December 2017, Pages 1794-1802

https://doi.org/10.1016/j.spinee.2017.05.029 Get rights and content

Abstract

Background Context

Sagittal imbalance is associated with poor clinical outcomes in patients with degenerative lumbar disease. However, there is no consensus on the impact of posterior lumbar interbody fusion (PLIF) on local and global sagittal balance.

Purpose

To reveal the effect of one- or two-level PLIF on global sagittal balance.

Design/Setting

A retrospective case-control study.

Patients Sample

This study included 88 patients who underwent a one- or two-level PLIF for spinal stenosis with spondylolisthesis.

Outcome Measures

Clinical and radiological parameters were measured pre- and postoperatively.

Methods

All patients were followed up for >2 years. Clinical outcomes included a visual analog scale, Oswestry Disability Index, and EuroQol 5-dimension questionnaire (EQ-5D). Radiological parameters were measured using whole-spine standing lateral radiographs. Fusion, loosening, subsidence rates, and adverse events were also evaluated. Patients were divided into two groups according to their preoperative C7–S1 sagittal vertical axis (SVA): Group N: SVA≤5 cm vs Group I: SVA>5 cm; they were also divided according to postoperative changes in C7–S1 SVA. Clinical and radiological outcomes were compared between the groups.

Results

All clinical outcomes and radiological parameters improved postoperatively. C7–S1 SVA improved (−1.6 cm) after L3–L5 fusion, but it was compromised (+3.6 cm) after L4–S1 fusion (p=.001). Preoperative demographic and clinical data showed no difference except in the anxiety or depression domain of EQ-5D. No differences were found in postoperative clinical outcomes. Lumbar lordosis, pelvic tilt, and thoracic kyphosis slightly improved in Group N, whereas C7–S1 SVA decreased from 9.5 cm to 3.8 cm (p<.001) in Group I. Furthermore, all sagittal parameters improved in Group I. On comparing the postoperative changes in C7–S1 SVA, we found that the decreasing trend in the postoperative C7–S1 SVA was related to a larger preoperative C7–S1 SVA (p=.030) and a more proximal level fusion (L3–L5 vs L4–S1, p=.033).

Conclusions

Global sagittal balance improved after short-level lumbar fusion surgery in patients having spinal stenosis with spondylolisthesis who showed preoperative sagittal imbalance. Restoration of sagittal balance predominantly occurred after L3–L4, L4–L5, or L3–L5 PLIF. However, no such restoration was observed after L5–S1 or L4–S1 PLIF. Thus, we could anticipate sagittal balance restoration after performing PLIF at L3–L4 or L4–L5 level. However, caution is required when planning for L5–S1 fusion if preoperative sagittal imbalance is present.

Introduction

Evidence & Methods

Studies assessing the impact of PLIF on sagittal balance have found varying results. The authors present their findings on the subject.

They found that PLIF at L3-4 and/or L4-L5 improved sagittal balance, whereas PLIF at L5-S1 or L4-S1 tended to have a negative impact.

Given the retrospective nature from a single institution in Korea, patient and surgeon (technical) factors may limit generalizability. That said, the take-home message that short segment fusion to the sacrum may be a risk for sagittal imbalance might be of value. Importantly, the authors noted no differences in functional outcomes based on pre- or post-operative imbalance, but longer-term follow-up should be considered prior to drawing conclusions.

Sagittal balance restoration needs to be considered when preparing for corrective surgery in patients with sagittal malalignment. For example, an adequate restoration of lumbar lordosis (LL) followed by an increase in thoracic kyphosis (TK) was required for good clinical and radiological outcomes in patients with lumbar degenerative kyphosis [1]. Recently, more focus has been placed on the importance of sagittal balance in the treatment of lumbar degenerative diseases and deformities, such as lumbar degenerative kyphosis. It was reported that pain, disability, and quality of life were related to sagittal imbalance in patients who underwent surgery for degenerative lumbar diseases, such as spinal stenosis or degenerative spondylolisthesis [2]. In the past, it was considered that even a short-level fusion had a deleterious effect on the sagittal balance, which included the loss of LL and sacral slope (SS) [3], [4], [5]. However, the importance of sagittal balance was not established at that time, and sagittal balance restoration in short-level lumbar fusion surgery was overlooked.

As the concept of lumbar sagittal profiles and global sagittal balance developed, many studies reported on the effect of various types of lumbar fusion surgeries on regional and global sagittal balance. It was reported that a lateral lumbar interbody fusion could improve regional sagittal profiles, although several studies reported that it could not change global sagittal alignment [6], [7], [8]. However, there is no consensus on the postoperative changes in global sagittal parameters following a short-level posterior lumbar interbody fusion (PLIF), which is frequently performed. Thus, the purpose of this study was (1) to reveal the impact of a one- or two-level PLIF on regional and global sagittal balance and (2) to compare clinical and radiological outcomes based on preoperative sagittal alignment.

Section snippets

Demographic and clinical data

Among 168 consecutive patients who underwent a one- or two-level posterior decompression and fusion for prolonged back or leg pain and intermittent claudication due to spinal stenosis with spondylolisthesis (≥grade 1), 88 were finally included in this study. All surgeries were performed by a single surgeon from March 2012 to December 2013, and patients were followed up for >2 years. Exclusion criteria were as follows: (1) posterolateral fusion; (2) revision surgery; (3) a >3-level involvement;

Results

In total, 24 males (27.3%) and 64 females (72.7%) who underwent a surgery were included in this analysis; of them, 57 and 31 underwent one-level and two-level PLIF, respectively. The L4–L5 level was the most frequently involved level (38 of 88, 43.2%), followed by L3–L5 (18 of 88, 20.5%), L4–S1 (11 of 88, 12.5%), and L5–S1 (11 of 88, 12.5%). The fusion rate was 96.6% (85 of 88) using dynamic radiographs and 80.7% (71 of 88) using CT. Computed tomography-based nonunion rates were 17.2% (10 of

Discussion

The importance of sagittal balance has been researched in patients with deformities such as lumbar degenerative kyphosis, degenerative scoliosis, ankylosing spondylitis, or complex deformity. If not sufficiently corrected, sagittal imbalance correlated with postoperative pain and functional disability [2]. Recently, sagittal balance has been discussed in patients with lumbar degenerative diseases, such as spinal stenosis, degenerative spondylolisthesis, or isthmic spondylolisthesis. It was

Acknowledgment

The authors would like to thank Mi Young Lee, Sungjoo Cheon, So Jung Yoon, and A Lyoun Lee for their help with data collection.

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Preoperative difference in lumbar lordosis (DiLL) was associated with surgical outcomes after single-level transforaminal lumbar interbody fusion (TLIF). Patients with DiLL>0 (DiLL (+)) tended to show worse clinical outcomes and postoperative greater restoration of lumbar lordosis (LL). However, some patients with DiLL (+) showed relatively good outcomes and no postoperative LL restration. This study aimed to elucidate whether the lumbar intervertebral disc vacuum phenomenon (VP) influences clinical course after single-level TLIF in patients with DiLL (+) and DiLL (−).
Patients with lumbar spinal stenosis and degenerative spondylolisthesis treated with single-level TLIF were included. Pre- and postoperative LL were measured, and postoperative LL improvement was calculated. Preoperative DiLL was calculated as preoperative supine LL minus standing LL. Severity of VP at the non-fused discs (SVP (non-FS)) was evaluated using preoperative reconstructed computed tomography imaging. Clinical outcomes were assessed using the Oswestry disability index, visual analogue scale (VAS; low back pain (LBP), lower-extremity pain, numbness, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Patients were stratified by the median preoperative SVP (non-FS) score into severe and mild VP groups in patients with DiLL (+) or DiLL (−), and their surgical outcomes were compared.
Overall, 89 patients were included. In patients with DiLL (+) (n = 37), patients with severe VP showed worse clinical outcomes, particulary for LBP and DiLL (+) patients with mild VP showed greater LL improvement (6.5° ± 10.0°). In patients with DiLL(−) (n = 52), patients with severe VP showed worse clinical outcomes, particularly for LBP and no differences in preoperative, postoperative, and improvement of LL were observed between two groups.
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Patients scheduled for L4−5 PLIF often have FS at L5-S1. However, data on the clinical and radiographic outcomes of cases with mild-to-moderate L5−S1 FS are lacking, which may affect clinical outcomes or require additional surgery after L4−5 fusion.
To evaluate the clinical and radiographic outcomes of L4−5 PLIF in patients with and without mild-to-moderate L5−S1 FS, with a primary focus on the association between L5−S1 FS and postoperative clinical outcomes including back pain, leg pain, and scores on the oswestry disability index (ODI) and EuroQol 5-dimension (EQ-5D).
Retrospective comparative study.
A retrospective review of patients who underwent L4−5 PLIF from 2014 to 2018. The patients were divided according to the presence of mild-to-moderate FS at L5−S1.
Clinical assessment included the pain visual analog scale (VAS), ODI, and EQ-5D score. Radiographic assessments included spinopelvic parameters and grades for central and foraminal stenosis.
Clinical outcomes were assessed using validated outcome measures at preoperative, 6-month, 12-month, and 36-month follow-up visits. Radiographic evaluations were performed using preoperative and postoperative radiographs. Foraminal stenosis was assessed qualitatively using MRI with a grading system from none to severe and quantitatively by measuring changes in the foraminal area on CT.
Among 186 patients, 55 were categorized as the FS group and 131 as the non-FS group. The FS group was older (p=0.039) and had more severe central stenosis at L5−S1 (p=0.007) as well as more severe FS at both L4−5 and L5−S1 (both p<0.001). Preoperative disc height (p<0.001), C7-S1 sagittal vertical axis (p=0.003), lumbar lordosis (p=0.005), and pelvic incidence–lumbar lordosis mismatch (p=0.026) were more aggravated in the FS group. The FS group showed inferior clinical outcomes at the final follow-up in terms of back pain (p=.010) and ODI score (p=.003).
The presence of mild-to-moderate FS at L5–S1 was associated with more aggravated sagittal balance in terms of smaller preoperative disc height, larger sagittal vertical axis, smaller lumbar lordosis, and larger pelvic incidence–lumbar lordosis mismatch. Patients with L5−S1 FS also had poorer clinical outcomes including back pain and ODI score after L4−5 PLIF. Patients with L5−S1 FS need to be carefully examined before L4−5 fusion considering their adverse outcomes due to underlying degenerative changes.
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To identify the risk factors for the aggravation of sagittal alignment after single-level L5–S1 PLIF.
Eighty-six patients who underwent L5–S1 PLIF were divided into 2 groups according to the postoperative changes in the segmental angle (SA; group I: increase; group D: decrease). The 2 groups were compared in terms of demographic, clinical, and radiological outcomes. Multivariate logistic regression analysis was performed to identify the risk factors for aggravation of sagittal alignment.
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: FDA device/drug status: Not applicable.

: Author disclosures: JHC: Nothing to disclose. Y-SJ: Nothing to disclose. CL: Nothing to disclose. CJH: Nothing to disclose. D-HL: Nothing to disclose. CSL: Nothing to disclose.

: This study received no funding.

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Clinical StudyEffect of one- or two-level posterior lumbar interbody fusion on global sagittal balance

Abstract

Background Context

Purpose

Design/Setting

Patients Sample

Outcome Measures

Methods

Results

Conclusions

Introduction

Section snippets

Demographic and clinical data

Results

Discussion

Acknowledgment

J Clin Neurosci

Spine J

Spine J

Influence of lumbar lordosis restoration on thoracic curve and sagittal position in lumbar degenerative kyphosis patients

Spine

Impact of sagittal spinopelvic alignment on clinical outcomes after decompression surgery for lumbar spinal canal stenosis without coronal imbalance

J Neurosurg Spine

Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain

Eur Spine J

Lumbar sagittal balance influences the clinical outcome after decompression and posterolateral spinal fusion for degenerative lumbar spondylolisthesis

Spine

Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion

Eur Spine J

Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study

J Neurosurg Spine

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance

Eur Spine J

Clinical Study
Effect of one- or two-level posterior lumbar interbody fusion on global sagittal balance