Patient, implant factors may lead to cage subsidence after lateral lumbar interbody fusion
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A systematic review showed poor bone density, multilevel surgery and use of narrow and tall cages may lead to cage subsidence or intraoperative endplate injury after lateral lumbar interbody fusion.
Searching Medline, Embase, Cochrane Library, PubMed and Web of Science databases from 1997 to 2020, two independent reviewers identified 34 articles with moderate to very low-quality evidence and 3,233 patients who reported risk factors for late-onset cage subsidence or intraoperative endplate injury after lateral lumbar interbody fusion. Researchers evaluated the role of bone quality and its surrogates in cage subsidence, as well as reviewed implant-related risk factors for intraoperative endplate injury or late-onset cage subsidence after lateral lumbar interbody fusion surgery.
Among 20 studies with moderate quality of evidence, researchers found eight studies reported risk factors for cage subsidence related to bone mineral density and its surrogates and 12 studies reported risk factors regarding implant factors.
Results showed a high risk of late-onset cage subsidence and intraoperative endplate injury among patients with a DXA T-score of –1 or less, age older than 65 years and female sex. Researchers found late-onset cage subsidence may be avoided with a cage width of 22 mm or greater and intraoperative endplate injury may be avoided with a cage height of 11 mm or less. Multilevel lateral lumbar interbody fusion had a high risk of losing the effect of indirect decompression and should be conducted with extra caution, according to results. Researchers noted patients without osteoporosis or obesity may sufficiently undergo standalone lateral lumbar interbody fusion, while surgeons should consider supplementary instrumentation among patients with multiple risk factors to maintain the postoperative disc height and prevent subsidence progression. Researchers found vague or controversial results around the effect of the bone graft, cage material, endplate condition and supplementary instrumentation on cage subsidence.
“The effect of the cage material and supplementary instrumentation require stronger evidence from prospectively designed studies with larger sample size that randomly assign patients to polyether-ether-ketone (PEEK) or titanium cages and different fixation types,” the authors wrote. “Future research on intraoperative endplate injuries should focus on the specific timing of when endplate violation occurs with the help of intraoperative imaging so that attempts can be made to minimize its occurrence.”
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