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A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery
Journal of Orthopaedic Science xxx (xxxx) xxx
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Original Article
A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery Masaaki Machino a, Kei Ando a, Kazuyoshi Kobayashi a, Kyotaro Ota a, Masayoshi Morozumi a, Satoshi Tanaka a, Keigo Ito b, Fumihiko Kato b, Naoki Ishiguro a, Shiro Imagama a, * a b
Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 October 2018 Received in revised form 23 December 2018 Accepted 14 February 2019 Available online xxx
Background: Optimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to osteoporotic vertebral fractures (OVFs) has been controversial. We assessed the usefulness, safety, and efficacy of posterior lumbar interbody fusion (PLIF) for LSS with neurological deficit due to OVFs and compared this procedure to posterior/anterior combined surgery (PACS). Methods: Of 36 consecutive patients with LSS with neurological deficit due to OVFs, 15 underwent PLIF (6 males, 9 females; mean age, 74 years), and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Surgical complications, clinical outcomes (operative time, blood loss, American Spinal Injury Association Impairment Scale [AIS], activities of daily living [ADLs]), and sagittal alignment were investigated. Bony fusion was assessed using plain and functional X-rays and computed tomography scans. Results: There were no significant differences in age, sex, or disease or follow-up duration between the groups. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF than in the PACS groups. AIS and ADL improved significantly postoperatively in both groups. No significant difference was observed in neurological improvement, correction angle, loss of correction, and surgical complications. No pseudarthrosis occurred, and no patient required additional surgery in the PLIF group. Conclusions: PLIF for LSS with neurological deficit due to OVFs achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This less invasive procedure is a useful reconstructive surgery option. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction The elderly comprise a rapidly increasing proportion of the population worldwide as life expectancies rise, according to data from the Global Burden of Disease Study 2010 [1]. The prevalence of age-specific diseases increases with age in all regions [2]. Thus, surgeries for lumbar degenerative diseases, such as lumbar
* Corresponding author. Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine 65, Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan. Fax: þ81 52 744 2260. E-mail address: [email protected] (S. Imagama).
degenerative spondylolisthesis or spinal deformity, also have increased [3e8]. Spinal fusion involving lumbar instrumentation is used widely to stabilize and provide better physiologic alignment in the spine [9,10]. Osteoporotic vertebral fractures (OVFs) are significant injuries producing functional loss in activities of daily living (ADLs) for an increasingly elderly population [11]. Compression OVFs are conventionally treated conservatively with rest, immobilization, analgesics, bracing, and physical therapy. Development of neurological deficits is typically associated with several factors, including direct neural compression from retropulsed bony fragments in the spinal canal, abnormal neural alignment subsequent to progressive
https://doi.org/10.1016/j.jos.2019.02.013 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
kyphosis, and dynamic neural damage due to abnormal mobility at the fracture site [12]. Decompression of neural elements and restoration of spinal stability are essential for surgical management of OVFs [13]. Patients with OVFs have relatively severe osteoporosis and often possess multiple preexisting vertebral compression fractures, leading to technical difficulty in achieving spinal reconstruction. Surgical treatment of OVFs is tailored to the individual patient because of the multiple comorbidities in the osteoporotic population [14,15]. Optimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to OVFs (LSS-OVFs) has been controversial [16,17]. Although widely performed [18e22], posterior lumbar interbody fusion (PLIF) has not been reported for LSS-OVFs to our knowledge. We assessed the usefulness and safety of PLIF for LSSOVFs and compared its efficacy with that of posterior/anterior combined surgery (PACS). 2. Materials and methods 2.1. Patient population Initially, all OVF patients were treated conservatively. Institutional review board approval was obtained for medical record review. Two common surgical interventions for OVFs at the lumbar spine have been in use: PACS since 1995 and PLIF since 2002. Of 36 consecutive patients with LSS-OVFs who underwent spinal surgery, 15 underwent PLIF (6 males, 9 females; mean age, 74 years) and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Patients with metastatic spinal tumors and/or a previous spinal surgical history were excluded from this study. The indication of PLIF was LSS-OVF case without severe vertebral collapse. PLIF was performed for either superior or inferior endplate fracture. The LSSOVF case with both superior and inferior endplate fracture was excluded for the indication of PLIF. No patient was treated with Teriparatide [PTH (1-34)] as engineered analog of human parathyroid hormone before and after surgery. 2.2. Surgical procedure 2.2.1. PLIF Group PLIF comprised interbody fusion and posterior fixation with a pedicle screw and hook system. The patient was placed on a Hall 4point frame in the prone position, thus producing gentle reduction force to correct the kyphotic deformity by altering body position. Achievement of reduction depended mainly on positioning and manual correction rather than instrumentation. A standard midline posterior approach was used. Careful dissection was performed up to the tips of the transverse processes of the fusion levels. Partial facetectomy and laminectomy up to the medial pedicle edge was performed. The entire inferior articular process and superior portion of the superior articular process on the side chosen for PLIF were removed using an osteotome and Kerrison rongeurs. Disc material was removed using pituitary rongeurs, rasps, and curettes. Endplate removal and decortication provided an excellent graft bed adjacent to the anterior annulus. Autogenous iliac crest bone graft mixed with local bone then was packed tightly into the anterior disc space with a bone tamp. A cage was used in all patients. After inserting posterior bilateral pedicle screws, the rods were contoured and set into the screw head. Posterior instrumentation was performed using pedicle screws and infralaminar hooks at the same levels as the pedicle screws. Concomitant use of the screws and hooks at the same level results in very strong fixation and decreases the risk of instrumentation failure. However, this procedure should be used with great caution. The locking plugs were tightened.
Compressive forces were applied to correct kyphosis that occurred during the procedure (Figs. 1 and 2). 2.2.2. PACS Group The PACS procedure consisted of posterior fixation using a pedicle screw and hook system, followed by anterior decompression and interbody fusion during the same anesthetic session. Posterior fixation was performed by placing two pedicle screws and one hook at one level above and one level below the injured vertebra with the patient in the prone position on a Hall frame. Next, the anterior procedure was performed via the retroperitoneal approach with the patient in the right decubitus position. Lateral and anterior aspects of the injured vertebral body were exposed. The collapsed body, including the posterior wall, was resected subtotally after removal of the discs above and below. Preservation of the endplates while removing the adjacent discs is crucial to prevent postoperative correction loss; therefore, the procedure was performed very carefully. After anterior decompression, anterior interbody fusion was performed using an anterior metal cage filled with cancellous bone chips harvested from the iliac crest (Fig. 3). 2.3. Postoperative treatment An ambulation and rehabilitation program was started on the day of drain removal (usually 2 days postoperatively). A custommade plastic thoracolumbosacral orthosis was used for approximately 6 months in all cases. 2.4. Clinical and radiographical evaluation Clinical outcomes (operative time, blood loss, postoperative recumbent period, and complications during the perioperative and postoperative periods) were investigated and compared between the two groups. The neurological status of each patient was assessed using the American Spinal Injury Association Impairment Scale (AIS). ADLs also were evaluated and classified as follows: stage 1, could walk by oneself; stage 2, could walk with help; stage 3, could not walk but could sit by oneself; and stage 4, could not sit by oneself. The sagittal alignment [local lordotic angle (LLA) of the fusion level] on the lateral view of plain radiographs was measured between the superior endplate of the upper and inferior endplate of the lower instrumented vertebra by the Cobb method. The LLA before and after surgery as well as at final follow-up were measured from plain and functional X-rays. postoperative LLA preoperative LLA) and correction loss (postoperative LLA LLA at final observation) were calculated. Bony fusion was evaluated by functional Xrays and a computerized tomography (CT) reconstruction scan. Plain radiographs, including flexioneextension views, were obtained to assess the fusion progress at 1, 3, and 6 months and 1 year postoperatively and at the latest follow-up. In addition, CT scans were obtained to assess fusion progress at 6 months and 1 year postoperatively and at the latest follow-up. Disappearance of a clear radiolucent zone at the border area on CT reconstruction scans was interpreted as an indication of successful fusion. Pedicle screw loosening was confirmed using postoperative CT scans, and pedicle screw cutout was defined for screws outside the pedicle. Postoperative adjacent vertebral fracture was confirmed using magnetic resonance image and radiographs. 2.5. Statistical analysis Two-tailed independent sample t-tests and Fisher exact tests were conducted to compare the outcomes in the PLIF and PACS
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
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Fig. 1. Representative case (a 73-year-old-female) of posterior lumbar interbody fusion (PLIF) at L3-4 level for a L4 osteoporotic vertebral fracture. Preoperative posteroanterior (A) and lateral (B) radiographs. Postoperative posteroanterior (C) and lateral (D) radiographs taken 2 years after surgery.
Fig. 2. Representative case of posterior lumbar interbody fusion (PLIF). Preoperative sagittal CT myelography (A). Postoperative sagittal (B) and axial (C) CT images taken 2 years after PLIF.
Fig. 3. Representative case (a 74-year-old-female) of posterior and anterior and combined surgery (PACS) at T12-L2 level for L1 osteoporotic vertebral fracture. Preoperative posteroanterior (A) and lateral (B) radiographs. Postoperative posteroanterior (C) and lateral (D) radiographs taken 2 years after surgery.
groups. P < 0.05 was considered significant. Statistical analyses were conducted using SPSS version 17 (SPSS, Inc., Chicago, IL, USA). 3. Results There were no significant differences in age, sex, or illness or follow-up durations, number of preexisting vertebral fractures, affected vertebra level and endplate fracture type between the groups. Fusion length, however, was significantly longer in the
PACS than in the PLIF groups (Table 1). There were no significant differences in preoperative and postoperative AIS or preoperative and postoperative ADL status between the groups (Tables 2 and 3). Neurological recovery of AIS and recovery of ADL stage were similar in both groups. Neurological deterioration did not occur in either group (Table 3). Mean operation time was 152 ± 34 and 232 ± 33 min, and mean blood loss was 215 ± 77 and 638 ± 442 mL in the PLIF and PACS groups, respectively. Operative time was significantly shorter and
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
Table 1 Summary of patient background data.
Number of cases Mean age (years) Sex (Male/Female) Illness duration (months) Number of preexisting VFs Affected vertebra Level
Table 4 Clinical and radiographical outcomes before and after surgery. PLIF Group
PACS Group P value
Item
PLIF Group
PACS Group
P value
15 74.2 ± 7.3 6/9 2.6 ± 2.0 3 (20%)
21 70.3 ± 6.9 4/17 2.3 ± 0.5 4 (19%)
Surgery time (minutes) Blood loss (mL) Recumbency period (days) Preoperative LLA (degrees) Postoperative LLA (degrees) LLA at final observation (degrees) Correction angle (degrees) Correction loss (degrees) Fusion rate (%)
152 ± 34 215 ± 77 2.1 ± 0.3 1.5 ± 8.0 6.6 ± 5.6 3.5 ± 8.4 8.1 ± 4.3 3.1 ± 4.2 15 (100%)
232 ± 33 638 ± 442 2.6 ± 0.8 2.6 ± 11.3 6.5 ± 9.7 3.0 ± 7.3 9.1 ± 5.4 3.5 ± 5.0 21 (100%)
<0.0001a <0.0001a 0.0160a 0.7371 0.9619 0.8600 0.1677 0.6231 1.0000
L1 1 L2 0 L3 5 L4 7 L5 2 Endplate fracture type (superior/inferior) 8/7 Fusion level 1.2 ± 0.6 Follow-up period (months) 40.0 ± 29.9
L1 5 L2 5 L3 6 L4 5 L5 0 11/10 2.0 ± 0.2 39.9 ± 24.6
0.1118 0.1664 0.4760 0.9433 0.0529
0.9550 <0.0001a 0.7272
Values given are mean ± SD unless otherwise specified. PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery; VFs, vertebral fractures. a Statistically significant values.
Table 2 Change in the American Spinal Injury Association impairment scale: preoperative to postoperative.
Preoperative A B C D E Postoperative A B C D E Neurological recovery (1 grade)
PLIF Group
PACS Group
P value
0 0 2 13 0
0 1 9 11 0
0.0929
0 0 0 4 11 80.0% (12 patients)
0 0 0 13 8 81.0% (17 patients)
0.0802
mean loss of correction was observed in the PLIF group, compared with 9.1 ± 5.4 mean correction and 3.5 ± 5.0 loss of correction in the PACS group. There were no significant differences in mean loss of correction between the groups. The postoperative fusion rate was 100% in both groups (Table 4). Regarding perioperative complications, one patient experienced delirium and one had a superficial wound infection in the PLIF group, whereas in the PACS group, five had delirium, two had respiratory complications, and one had a superficial wound infection. Postoperative complications included pedicle screw loosening and adjacent vertebral fracture in one patient in each group. One patient (PACS group) underwent pedicle screw cutout, and one (PACS group) with adjacent vertebral fracture underwent reoperation because of severe lower back pain 1 year postoperatively. There were no significant differences in surgical complication between the groups (Table 5).
0.9433
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
Table 3 Change in the ADL stage: preoperative to postoperative.
Preoperative Stage 1 Stage 2 Stage 3 Stage 4 Postoperative Stage 1 Stage 2 Stage 3 Stage 4 ADL recovery (1 stage)
Values given are mean ± SD unless otherwise specified. PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery. LLA: local lordotic angle. Correction angle ¼ postoperative LLA preoperative LLA. Correction loss ¼ postoperative LLA LLA at final observation. a Statistically significant values.
PLIF Group
PACS Group
P value
1 1 12 1
0 5 14 2
0.3555
5 8 2 0 86.7% (13 patients)
5 14 2 0 81.0% (17 patients)
0.7209
0.6501
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
intraoperative blood loss significantly less in the PLIF than in the PACS groups. Recumbency period was significantly shorter in the PLIF group (Table 4). Mean LLA was 1.5 ± 8.0, 6.6 ± 5.6, and 3.5 ± 8.4 preoperatively, postoperatively, and at final follow-up, respectively, in the PLIF group, and 2.6 ± 11.3, 6.5 ± 9.7, and 3.0 ± 7.3, respectively, in the PACS group. Immediately postoperatively, 8.1 ± 4.3 mean correction from preoperative levels was observed for kyphosis, but 3.1 ± 4.2
4. Discussion To our knowledge, use of the PLIF technique in the patients with LSS-OVFs has never been reported. We compared the surgical results of PLIF and PACS procedures for treatment of LSS-OVFs. Neurological recovery was almost the same with both procedures. Perioperative and postoperative complication rates were also almost identical. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF group compared with results in the PACS group. Recumbency period in the PLIF group was significantly shorter than that in the PACS group. Therefore, PLIF is less invasive and can be a useful reconstructive surgery option for patients with LSS-OVFs.
Table 5 Peri- and Postoperative complications.
Perioperative Delirium (case) Pneumonia or atelectasis (case) Dural tear (case) Superficial wound infection (case) Postoperative Pedicle screw loosening (case) Adjacent vertebral fracture (case) Pedicle screw cut out (case) Reoperation (case)
PLIF Group
PACS Group
P value
1 0 0 1
5 2 0 1
0.1736 0.2187 1.0000 0.8057
1 1 0 0
1 1 1 1
0.8057 0.8057 0.3914 0.3914
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
OVFs are often associated with progressive kyphotic deformity and neural tissue compression and are amenable only to major surgical intervention [3e6]. However, there is controversy regarding which spinal reconstruction method is most appropriate [23e26]. Commonly reported techniques include anterior fusion only, posterior fusion alone, and PACS [27]. The main goals of surgery for OVFs are to achieve adequate decompression of the spinal canal to maximize neurological recovery, enable early mobilization and rehabilitation, and create spinal stability, thus preventing painful deformity and potential future neurological deterioration. Posterior fusion techniques sometimes are used when there is traumatic damage to the anterior column [19,20]. Posterior reduction and stabilization without consolidation of the anterior gap increases the risk of loss of reduction, instrumentation failure, and pseudarthrosis [28]. For example, a long segmental fusion usually is performed because of lack of anterior stability; however, such fusion decreases range of motion and interferes with ADL [11,29]. A short segmental fusion cannot bear the load and might induce postoperative loss of deformity correction or instrumentation failure [15]. The obvious advantages of the posterior approach are its familiarity to all spinal surgeons and the relative ease of placing pedicle screws [19,20]. PLIF can substitute these conventional procedures [25]. During PLIF, it is possible to manipulate the interbody discs and reconstruct the anterior column through interbody bone grafts using a posterior approach alone, enabling posterior rigid fixation and reconstruction of an anterior load support. Apposition of the vertebral endplates under compression allows for an excellent interbody fusion rate. The associated posterior segmental fixation provides a solid and strong construct with immediate stability, allowing for early mobilization and a sitting position [30]. An additional anterior approach is not necessary, because there is no anterior defect to fill. Bleeding loss and perioperative complications are acceptable. In our study, the clinical outcomes of PLIF were comparable with those of PACS in terms of operative invasion, improvement in neurological deficit, and bony fusion. The PLIF technique represents a less invasive surgical option compared with PACS. The postoperative recumbency also was shorter with PLIF than with PACS. Although PLIF was able to correct the LLA by 8.1 on average, a few corrective losses were observed during follow-up, similar to the results of PACS. In a previous report, PACS simultaneously achieved anterior reconstruction and stable posterior fixation; however, this procedure required two skin incisions and was more invasive [27]. PLIF can be considered an option for management of LSS with neurological deficit due to OVF. Our study had several limitations. We reported the clinical outcome of the first 15 cases performed at our institution. We compared patients who underwent PLIF and PACS. However, the patients were not divided randomly, and those in the PACS group had been treated previously. Although preoperative evaluation of bone quality was not investigated, there was no difference in the number of preexisting vertebral fractures between PLIF group and PACS group. The global sagittal balance such as SVA was not investigated in the current study. These measures should be included in further studies. We understand that our study involved a limited number of cases. However, this is a preliminary report, and we intend to recruit additional patients and observe them for a longer period. Prospective large-scale long-term follow-up studies are needed in the future. In conclusion, PLIF achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This procedure is less invasive than PACS and can be a useful reconstructive option for LSS-OVFs.
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Conflict of interest No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. The Institutional Review Board in our institution approved this study, and written informed consent was obtained from each patient before study participation or surgery. The authors declare no conflict of interest. Disclosure None of the authors have conflict of interest. No benefits in any form have been or will be received from commercial party related directly or indirectly to subject of this manuscript. 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Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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[17] Sasaki M, Aoki M, Nishioka K, Yoshimine T. Radiculopathy caused by osteoporotic vertebral fractures in the lumbar spine. Neurol Med -Chir 2011 July;51(7):484e9. [18] Kanemura T, Matsumoto A, Ishikawa Y, Yamaguchi H, Satake K, Ito Z, Yoshida G, Sakai Y, Imagama S, Kawakami N. Radiographic changes in patients with pseudarthrosis after posterior lumbar interbody arthrodesis using carbon interbody cages: a prospective five-year study. J Bone Joint Surg Am 2014 May 21;96(10):e82. [19] Machino M, Yukawa Y, Ito K, Nakashima H, Kato F. A new thoracic reconstruction technique “transforaminal thoracic interbody fusion (TTIF)”: a preliminary report of clinical outcomes. Spine 2010 Sep 1;35(19):E1000e5. [20] Machino M, Yukawa Y, Ito K, Nakashima H, Kanbara S, Morita D, Kato F. Transforaminal thoracic interbody fusion" in the management of lower thoracic spine fracture-dislocations: technical note. J Spinal Disord Tech 2013 Aug;26(6):E209e14. [21] Nakashima H, Kawakami N, Tsuji T, Ohara T, Suzuki Y, Saito T, Nohara A, Tauchi R, Ohta K, Hamajima N, Imagama S. Adjacent segment disease after posterior lumbar interbody fusion: based on cases with a minimum of 10 Years of follow-up. Spine 2015 Jul 15;40(14):E831e41. [22] Imagama S, Kawakami N, Matsubara Y, Tsuji T, Ohara T, Katayama Y, Ishiguro N, Kanemura T. Radiographic adjacent segment degeneration at 5 Years after L4/5 posterior lumbar interbody fusion with pedicle screw instrumentation: evaluation by computed tomography and annual screening with magnetic resonance imaging. Clin Spine Surg 2016 Nov;29(9):E442e51. [23] Suk SI, Kim JH, Lee SM, Chung ER, Lee JH. Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture. Spine 2003 Sep 15;28(18):2170e5. [24] Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C. Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine 2007 Sep 15;32(20):2189e97. [25] Kanayama M, Ishida T, Hashimoto T, Shigenobu K, Togawa D, Oha F, Kaneda K. Role of major spine surgery using Kaneda anterior instrumentation for osteoporotic vertebral collapse. J Spinal Disord Tech 2010 Feb;23(1):53e6. [26] Uchida K, Nakajima H, Yayama T, Miyazaki T, Hirai T, Kobayashi S, Chen K, Guerrero AR, Baba H. Vertebroplasty-augmented short-segment posterior fixation of osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine: comparisons with posterior surgery without vertebroplasty and anterior surgery. J Neurosurg Spine 2010 Nov;13(5):612e21. [27] Machino M, Yukawa Y, Ito K, Nakashima H, Kato F. Posterior/anterior combined surgery for thoracolumbar burst fractures. Posterior instrumentation with pedicle screws and laminar hooks, anterior decompression and strutgrafting. Spinal Cord 2011 Apr;49(4):573e9. [28] Lim TH, An HS, Hong JH. Biomechanical evaluation of anterior and posterior fixations in an unstable calf spine model. Spine 1997 Feb 1;22(3):261e6. [29] Nakashima H, Imagama S, Yukawa Y, Kanemura T, Kamiya M, Deguchi M, Wakao N, Sato T, Matsuzaki K, Yoshida G, Matsuyama Y, Ishiguro N, Kato F. Comparative study of 2 surgical procedures for osteoporotic delayed vertebral collapse: anterior and posterior combined surgery versus posterior spinal fusion with vertebroplasty. Spine 2015 Jan 15;40(2):E120e6. [30] Sasso RC, Colter HB, Reuben JD. Posterior fixation of thoracic and lumbar spine fractures using DC plates and pedicle screws. Spine 1991 Mar;16(Suppl. 3): S134e9.
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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Original Article
A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery Masaaki Machino a, Kei Ando a, Kazuyoshi Kobayashi a, Kyotaro Ota a, Masayoshi Morozumi a, Satoshi Tanaka a, Keigo Ito b, Fumihiko Kato b, Naoki Ishiguro a, Shiro Imagama a, * a b
Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 October 2018 Received in revised form 23 December 2018 Accepted 14 February 2019 Available online xxx
Background: Optimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to osteoporotic vertebral fractures (OVFs) has been controversial. We assessed the usefulness, safety, and efficacy of posterior lumbar interbody fusion (PLIF) for LSS with neurological deficit due to OVFs and compared this procedure to posterior/anterior combined surgery (PACS). Methods: Of 36 consecutive patients with LSS with neurological deficit due to OVFs, 15 underwent PLIF (6 males, 9 females; mean age, 74 years), and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Surgical complications, clinical outcomes (operative time, blood loss, American Spinal Injury Association Impairment Scale [AIS], activities of daily living [ADLs]), and sagittal alignment were investigated. Bony fusion was assessed using plain and functional X-rays and computed tomography scans. Results: There were no significant differences in age, sex, or disease or follow-up duration between the groups. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF than in the PACS groups. AIS and ADL improved significantly postoperatively in both groups. No significant difference was observed in neurological improvement, correction angle, loss of correction, and surgical complications. No pseudarthrosis occurred, and no patient required additional surgery in the PLIF group. Conclusions: PLIF for LSS with neurological deficit due to OVFs achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This less invasive procedure is a useful reconstructive surgery option. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction The elderly comprise a rapidly increasing proportion of the population worldwide as life expectancies rise, according to data from the Global Burden of Disease Study 2010 [1]. The prevalence of age-specific diseases increases with age in all regions [2]. Thus, surgeries for lumbar degenerative diseases, such as lumbar
* Corresponding author. Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine 65, Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan. Fax: þ81 52 744 2260. E-mail address: [email protected] (S. Imagama).
degenerative spondylolisthesis or spinal deformity, also have increased [3e8]. Spinal fusion involving lumbar instrumentation is used widely to stabilize and provide better physiologic alignment in the spine [9,10]. Osteoporotic vertebral fractures (OVFs) are significant injuries producing functional loss in activities of daily living (ADLs) for an increasingly elderly population [11]. Compression OVFs are conventionally treated conservatively with rest, immobilization, analgesics, bracing, and physical therapy. Development of neurological deficits is typically associated with several factors, including direct neural compression from retropulsed bony fragments in the spinal canal, abnormal neural alignment subsequent to progressive
https://doi.org/10.1016/j.jos.2019.02.013 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
kyphosis, and dynamic neural damage due to abnormal mobility at the fracture site [12]. Decompression of neural elements and restoration of spinal stability are essential for surgical management of OVFs [13]. Patients with OVFs have relatively severe osteoporosis and often possess multiple preexisting vertebral compression fractures, leading to technical difficulty in achieving spinal reconstruction. Surgical treatment of OVFs is tailored to the individual patient because of the multiple comorbidities in the osteoporotic population [14,15]. Optimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to OVFs (LSS-OVFs) has been controversial [16,17]. Although widely performed [18e22], posterior lumbar interbody fusion (PLIF) has not been reported for LSS-OVFs to our knowledge. We assessed the usefulness and safety of PLIF for LSSOVFs and compared its efficacy with that of posterior/anterior combined surgery (PACS). 2. Materials and methods 2.1. Patient population Initially, all OVF patients were treated conservatively. Institutional review board approval was obtained for medical record review. Two common surgical interventions for OVFs at the lumbar spine have been in use: PACS since 1995 and PLIF since 2002. Of 36 consecutive patients with LSS-OVFs who underwent spinal surgery, 15 underwent PLIF (6 males, 9 females; mean age, 74 years) and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Patients with metastatic spinal tumors and/or a previous spinal surgical history were excluded from this study. The indication of PLIF was LSS-OVF case without severe vertebral collapse. PLIF was performed for either superior or inferior endplate fracture. The LSSOVF case with both superior and inferior endplate fracture was excluded for the indication of PLIF. No patient was treated with Teriparatide [PTH (1-34)] as engineered analog of human parathyroid hormone before and after surgery. 2.2. Surgical procedure 2.2.1. PLIF Group PLIF comprised interbody fusion and posterior fixation with a pedicle screw and hook system. The patient was placed on a Hall 4point frame in the prone position, thus producing gentle reduction force to correct the kyphotic deformity by altering body position. Achievement of reduction depended mainly on positioning and manual correction rather than instrumentation. A standard midline posterior approach was used. Careful dissection was performed up to the tips of the transverse processes of the fusion levels. Partial facetectomy and laminectomy up to the medial pedicle edge was performed. The entire inferior articular process and superior portion of the superior articular process on the side chosen for PLIF were removed using an osteotome and Kerrison rongeurs. Disc material was removed using pituitary rongeurs, rasps, and curettes. Endplate removal and decortication provided an excellent graft bed adjacent to the anterior annulus. Autogenous iliac crest bone graft mixed with local bone then was packed tightly into the anterior disc space with a bone tamp. A cage was used in all patients. After inserting posterior bilateral pedicle screws, the rods were contoured and set into the screw head. Posterior instrumentation was performed using pedicle screws and infralaminar hooks at the same levels as the pedicle screws. Concomitant use of the screws and hooks at the same level results in very strong fixation and decreases the risk of instrumentation failure. However, this procedure should be used with great caution. The locking plugs were tightened.
Compressive forces were applied to correct kyphosis that occurred during the procedure (Figs. 1 and 2). 2.2.2. PACS Group The PACS procedure consisted of posterior fixation using a pedicle screw and hook system, followed by anterior decompression and interbody fusion during the same anesthetic session. Posterior fixation was performed by placing two pedicle screws and one hook at one level above and one level below the injured vertebra with the patient in the prone position on a Hall frame. Next, the anterior procedure was performed via the retroperitoneal approach with the patient in the right decubitus position. Lateral and anterior aspects of the injured vertebral body were exposed. The collapsed body, including the posterior wall, was resected subtotally after removal of the discs above and below. Preservation of the endplates while removing the adjacent discs is crucial to prevent postoperative correction loss; therefore, the procedure was performed very carefully. After anterior decompression, anterior interbody fusion was performed using an anterior metal cage filled with cancellous bone chips harvested from the iliac crest (Fig. 3). 2.3. Postoperative treatment An ambulation and rehabilitation program was started on the day of drain removal (usually 2 days postoperatively). A custommade plastic thoracolumbosacral orthosis was used for approximately 6 months in all cases. 2.4. Clinical and radiographical evaluation Clinical outcomes (operative time, blood loss, postoperative recumbent period, and complications during the perioperative and postoperative periods) were investigated and compared between the two groups. The neurological status of each patient was assessed using the American Spinal Injury Association Impairment Scale (AIS). ADLs also were evaluated and classified as follows: stage 1, could walk by oneself; stage 2, could walk with help; stage 3, could not walk but could sit by oneself; and stage 4, could not sit by oneself. The sagittal alignment [local lordotic angle (LLA) of the fusion level] on the lateral view of plain radiographs was measured between the superior endplate of the upper and inferior endplate of the lower instrumented vertebra by the Cobb method. The LLA before and after surgery as well as at final follow-up were measured from plain and functional X-rays. postoperative LLA preoperative LLA) and correction loss (postoperative LLA LLA at final observation) were calculated. Bony fusion was evaluated by functional Xrays and a computerized tomography (CT) reconstruction scan. Plain radiographs, including flexioneextension views, were obtained to assess the fusion progress at 1, 3, and 6 months and 1 year postoperatively and at the latest follow-up. In addition, CT scans were obtained to assess fusion progress at 6 months and 1 year postoperatively and at the latest follow-up. Disappearance of a clear radiolucent zone at the border area on CT reconstruction scans was interpreted as an indication of successful fusion. Pedicle screw loosening was confirmed using postoperative CT scans, and pedicle screw cutout was defined for screws outside the pedicle. Postoperative adjacent vertebral fracture was confirmed using magnetic resonance image and radiographs. 2.5. Statistical analysis Two-tailed independent sample t-tests and Fisher exact tests were conducted to compare the outcomes in the PLIF and PACS
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
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Fig. 1. Representative case (a 73-year-old-female) of posterior lumbar interbody fusion (PLIF) at L3-4 level for a L4 osteoporotic vertebral fracture. Preoperative posteroanterior (A) and lateral (B) radiographs. Postoperative posteroanterior (C) and lateral (D) radiographs taken 2 years after surgery.
Fig. 2. Representative case of posterior lumbar interbody fusion (PLIF). Preoperative sagittal CT myelography (A). Postoperative sagittal (B) and axial (C) CT images taken 2 years after PLIF.
Fig. 3. Representative case (a 74-year-old-female) of posterior and anterior and combined surgery (PACS) at T12-L2 level for L1 osteoporotic vertebral fracture. Preoperative posteroanterior (A) and lateral (B) radiographs. Postoperative posteroanterior (C) and lateral (D) radiographs taken 2 years after surgery.
groups. P < 0.05 was considered significant. Statistical analyses were conducted using SPSS version 17 (SPSS, Inc., Chicago, IL, USA). 3. Results There were no significant differences in age, sex, or illness or follow-up durations, number of preexisting vertebral fractures, affected vertebra level and endplate fracture type between the groups. Fusion length, however, was significantly longer in the
PACS than in the PLIF groups (Table 1). There were no significant differences in preoperative and postoperative AIS or preoperative and postoperative ADL status between the groups (Tables 2 and 3). Neurological recovery of AIS and recovery of ADL stage were similar in both groups. Neurological deterioration did not occur in either group (Table 3). Mean operation time was 152 ± 34 and 232 ± 33 min, and mean blood loss was 215 ± 77 and 638 ± 442 mL in the PLIF and PACS groups, respectively. Operative time was significantly shorter and
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
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M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
Table 1 Summary of patient background data.
Number of cases Mean age (years) Sex (Male/Female) Illness duration (months) Number of preexisting VFs Affected vertebra Level
Table 4 Clinical and radiographical outcomes before and after surgery. PLIF Group
PACS Group P value
Item
PLIF Group
PACS Group
P value
15 74.2 ± 7.3 6/9 2.6 ± 2.0 3 (20%)
21 70.3 ± 6.9 4/17 2.3 ± 0.5 4 (19%)
Surgery time (minutes) Blood loss (mL) Recumbency period (days) Preoperative LLA (degrees) Postoperative LLA (degrees) LLA at final observation (degrees) Correction angle (degrees) Correction loss (degrees) Fusion rate (%)
152 ± 34 215 ± 77 2.1 ± 0.3 1.5 ± 8.0 6.6 ± 5.6 3.5 ± 8.4 8.1 ± 4.3 3.1 ± 4.2 15 (100%)
232 ± 33 638 ± 442 2.6 ± 0.8 2.6 ± 11.3 6.5 ± 9.7 3.0 ± 7.3 9.1 ± 5.4 3.5 ± 5.0 21 (100%)
<0.0001a <0.0001a 0.0160a 0.7371 0.9619 0.8600 0.1677 0.6231 1.0000
L1 1 L2 0 L3 5 L4 7 L5 2 Endplate fracture type (superior/inferior) 8/7 Fusion level 1.2 ± 0.6 Follow-up period (months) 40.0 ± 29.9
L1 5 L2 5 L3 6 L4 5 L5 0 11/10 2.0 ± 0.2 39.9 ± 24.6
0.1118 0.1664 0.4760 0.9433 0.0529
0.9550 <0.0001a 0.7272
Values given are mean ± SD unless otherwise specified. PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery; VFs, vertebral fractures. a Statistically significant values.
Table 2 Change in the American Spinal Injury Association impairment scale: preoperative to postoperative.
Preoperative A B C D E Postoperative A B C D E Neurological recovery (1 grade)
PLIF Group
PACS Group
P value
0 0 2 13 0
0 1 9 11 0
0.0929
0 0 0 4 11 80.0% (12 patients)
0 0 0 13 8 81.0% (17 patients)
0.0802
mean loss of correction was observed in the PLIF group, compared with 9.1 ± 5.4 mean correction and 3.5 ± 5.0 loss of correction in the PACS group. There were no significant differences in mean loss of correction between the groups. The postoperative fusion rate was 100% in both groups (Table 4). Regarding perioperative complications, one patient experienced delirium and one had a superficial wound infection in the PLIF group, whereas in the PACS group, five had delirium, two had respiratory complications, and one had a superficial wound infection. Postoperative complications included pedicle screw loosening and adjacent vertebral fracture in one patient in each group. One patient (PACS group) underwent pedicle screw cutout, and one (PACS group) with adjacent vertebral fracture underwent reoperation because of severe lower back pain 1 year postoperatively. There were no significant differences in surgical complication between the groups (Table 5).
0.9433
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
Table 3 Change in the ADL stage: preoperative to postoperative.
Preoperative Stage 1 Stage 2 Stage 3 Stage 4 Postoperative Stage 1 Stage 2 Stage 3 Stage 4 ADL recovery (1 stage)
Values given are mean ± SD unless otherwise specified. PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery. LLA: local lordotic angle. Correction angle ¼ postoperative LLA preoperative LLA. Correction loss ¼ postoperative LLA LLA at final observation. a Statistically significant values.
PLIF Group
PACS Group
P value
1 1 12 1
0 5 14 2
0.3555
5 8 2 0 86.7% (13 patients)
5 14 2 0 81.0% (17 patients)
0.7209
0.6501
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
intraoperative blood loss significantly less in the PLIF than in the PACS groups. Recumbency period was significantly shorter in the PLIF group (Table 4). Mean LLA was 1.5 ± 8.0, 6.6 ± 5.6, and 3.5 ± 8.4 preoperatively, postoperatively, and at final follow-up, respectively, in the PLIF group, and 2.6 ± 11.3, 6.5 ± 9.7, and 3.0 ± 7.3, respectively, in the PACS group. Immediately postoperatively, 8.1 ± 4.3 mean correction from preoperative levels was observed for kyphosis, but 3.1 ± 4.2
4. Discussion To our knowledge, use of the PLIF technique in the patients with LSS-OVFs has never been reported. We compared the surgical results of PLIF and PACS procedures for treatment of LSS-OVFs. Neurological recovery was almost the same with both procedures. Perioperative and postoperative complication rates were also almost identical. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF group compared with results in the PACS group. Recumbency period in the PLIF group was significantly shorter than that in the PACS group. Therefore, PLIF is less invasive and can be a useful reconstructive surgery option for patients with LSS-OVFs.
Table 5 Peri- and Postoperative complications.
Perioperative Delirium (case) Pneumonia or atelectasis (case) Dural tear (case) Superficial wound infection (case) Postoperative Pedicle screw loosening (case) Adjacent vertebral fracture (case) Pedicle screw cut out (case) Reoperation (case)
PLIF Group
PACS Group
P value
1 0 0 1
5 2 0 1
0.1736 0.2187 1.0000 0.8057
1 1 0 0
1 1 1 1
0.8057 0.8057 0.3914 0.3914
PLIF indicates posterior lumbar interbody fusion; PACS, posterior/anterior combined surgery.
Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013
M. Machino et al. / Journal of Orthopaedic Science xxx (xxxx) xxx
OVFs are often associated with progressive kyphotic deformity and neural tissue compression and are amenable only to major surgical intervention [3e6]. However, there is controversy regarding which spinal reconstruction method is most appropriate [23e26]. Commonly reported techniques include anterior fusion only, posterior fusion alone, and PACS [27]. The main goals of surgery for OVFs are to achieve adequate decompression of the spinal canal to maximize neurological recovery, enable early mobilization and rehabilitation, and create spinal stability, thus preventing painful deformity and potential future neurological deterioration. Posterior fusion techniques sometimes are used when there is traumatic damage to the anterior column [19,20]. Posterior reduction and stabilization without consolidation of the anterior gap increases the risk of loss of reduction, instrumentation failure, and pseudarthrosis [28]. For example, a long segmental fusion usually is performed because of lack of anterior stability; however, such fusion decreases range of motion and interferes with ADL [11,29]. A short segmental fusion cannot bear the load and might induce postoperative loss of deformity correction or instrumentation failure [15]. The obvious advantages of the posterior approach are its familiarity to all spinal surgeons and the relative ease of placing pedicle screws [19,20]. PLIF can substitute these conventional procedures [25]. During PLIF, it is possible to manipulate the interbody discs and reconstruct the anterior column through interbody bone grafts using a posterior approach alone, enabling posterior rigid fixation and reconstruction of an anterior load support. Apposition of the vertebral endplates under compression allows for an excellent interbody fusion rate. The associated posterior segmental fixation provides a solid and strong construct with immediate stability, allowing for early mobilization and a sitting position [30]. An additional anterior approach is not necessary, because there is no anterior defect to fill. Bleeding loss and perioperative complications are acceptable. In our study, the clinical outcomes of PLIF were comparable with those of PACS in terms of operative invasion, improvement in neurological deficit, and bony fusion. The PLIF technique represents a less invasive surgical option compared with PACS. The postoperative recumbency also was shorter with PLIF than with PACS. Although PLIF was able to correct the LLA by 8.1 on average, a few corrective losses were observed during follow-up, similar to the results of PACS. In a previous report, PACS simultaneously achieved anterior reconstruction and stable posterior fixation; however, this procedure required two skin incisions and was more invasive [27]. PLIF can be considered an option for management of LSS with neurological deficit due to OVF. Our study had several limitations. We reported the clinical outcome of the first 15 cases performed at our institution. We compared patients who underwent PLIF and PACS. However, the patients were not divided randomly, and those in the PACS group had been treated previously. Although preoperative evaluation of bone quality was not investigated, there was no difference in the number of preexisting vertebral fractures between PLIF group and PACS group. The global sagittal balance such as SVA was not investigated in the current study. These measures should be included in further studies. We understand that our study involved a limited number of cases. However, this is a preliminary report, and we intend to recruit additional patients and observe them for a longer period. Prospective large-scale long-term follow-up studies are needed in the future. In conclusion, PLIF achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This procedure is less invasive than PACS and can be a useful reconstructive option for LSS-OVFs.
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Conflict of interest No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. The Institutional Review Board in our institution approved this study, and written informed consent was obtained from each patient before study participation or surgery. The authors declare no conflict of interest. Disclosure None of the authors have conflict of interest. No benefits in any form have been or will be received from commercial party related directly or indirectly to subject of this manuscript. 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Please cite this article as: Machino M et al., A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.02.013