Biomechanical comparison of multilevel lateral interbody fusion with and without supplementary instrumentation: a three-dimensional finite element study

BackgroundLateral lumbar interbody fusion (LLIF) is a popular, minimally invasive technique that is used to address challenging multilevel degenerative spinal diseases. It remains controversial whether supplemental instrumentation should be added for multilevel LLIF. In this study, we compared the kinematic stability afforded by stand-alone lateral cages with those supplemented by bilateral pedicle screws and rods (PSR), unilateral PSR, or lateral plate (LP) fixation using a finite-element (FE) model of a multi-level LLIF construct with simulated osteoporosis. Additionally, to evaluate the prospect of cage subsidence, the stress change characteristics were surveyed at cage-endplate interfaces.MethodsA nonlinear 3-dimensional FE model of the lumbar spine (L2 to sacrum) was used. After validation, four patterns of instrumented 3-level LLIF (L2-L5) were constructed for this analysis: (a) 3 stand-alone lateral cages (SLC), (b) 3 lateral cages with lateral plate and two screws (parallel to endplate) fixated separately (LPC), (c) 3 lateral cages with bilateral pedicle screw and rod fixation (LC + BPSR), and (d) 3 lateral cages with unilateral pedicle and rod fixation (LC + UPSR). The segmental and overall range of motion (ROM) of each implanted condition were investigated and compared with the intact model. The peak von Mises stresses upon each (superior) endplate and the stress distribution were used for analysis.ResultsBPSR provided the maximum reduction of ROM among the configurations at every plane of motion (66.7–90.9% of intact spine). UPSR also provided significant segmental ROM reduction (45.0–88.3%). SLC provided a minimal restriction of ROM (10.0–75.1%), and LPC was found to be less stable than both posterior fixation (23.9–86.2%) constructs. The construct with stand-alone lateral cages generated greater endplate stresses than did any of the other multilevel LLIF models. For the L3, L4 and L5 endplates, peak endplate stresses caused by the SLC construct exceeded the BPSR group by 52.7, 63.8, and 54.2% in flexion, 22.3, 40.1, and 31.4% in extension, 170.2, 175.1, and 134.0% in lateral bending, and 90.7, 45.5, and 30.0% in axial rotation, respectively. The stresses tended to be more concentrated at the periphery of the endplates.ConclusionsSLC and LPC provided inadequate ROM restriction for the multilevel LLIF constructs, whereas lateral cages with BPSR or UPSR fixation provided favorable biomechanical stability. Moreover, SLC generated significantly higher endplate stress compared with supplemental instrumentation, which may have increased the risk of cage subsidence. Further biomechanical and clinical studies are required to validate our FEA findings.

[1]  E. Kogias,et al.  Accidental Durotomy in Minimally Invasive Transforaminal Lumbar Interbody Fusion: Frequency, Risk Factors, and Management , 2015, TheScientificWorldJournal.

[2]  N. Anand,et al.  Long-term 2- to 5-Year Clinical and Functional Outcomes of Minimally Invasive Surgery for Adult Scoliosis , 2013, Spine.

[3]  Juan S. Uribe,et al.  Stand-alone minimally invasive lateral lumbar interbody fusion: Multicenter clinical outcomes , 2015, Journal of Clinical Neuroscience.

[4]  Jae Yong Ahn,et al.  Effects of Rigidity of an Internal Fixation Device A Comprehensive Biomechanical Investigation , 1991, Spine.

[5]  Stephen J. Ferguson,et al.  Factors influencing stresses in the lumbar spine after the insertion of intervertebral cages: finite element analysis , 2003, European Spine Journal.

[6]  R. Lehman,et al.  Bilateral pedicle screw fixation provides superior biomechanical stability in transforaminal lumbar interbody fusion: a finite element study. , 2015, The spine journal : official journal of the North American Spine Society.

[7]  Lutz Claes,et al.  Application of a new calibration method for a three-dimensional finite element model of a human lumbar annulus fibrosus. , 2006, Clinical biomechanics.

[8]  G. Malham,et al.  Assessment and classification of subsidence after lateral interbody fusion using serial computed tomography. , 2015, Journal of neurosurgery. Spine.

[9]  J. van Limbeek,et al.  PEEK Cages in Lumbar Fusion: Mid-term Clinical Outcome and Radiologic Fusion , 2012, Clinical Spine Surgery.

[10]  N. Abdala,et al.  Stand-Alone Lateral Interbody Fusion for the Treatment of Low-Grade Degenerative Spondylolisthesis , 2012, TheScientificWorldJournal.

[11]  T. J. Lim,et al.  Biomechanical Evaluation of an Interspinous Stabilizing Device, Locker , 2008, Spine.

[12]  C. Lamartina,et al.  Far lateral approaches (XLIF) in adult scoliosis , 2013, European Spine Journal.

[13]  M. Dekutoski,et al.  Sagittal Balance and Spinopelvic Parameters After Lateral Lumbar Interbody Fusion for Degenerative Scoliosis: A Case-Control Study , 2014, Spine.

[14]  H. Hey,et al.  Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Intermediate Results and Complications , 2015, Asian spine journal.

[15]  G. Malham,et al.  Maintenance of Segmental Lordosis and Disk Height in Stand-alone and Instrumented Extreme Lateral Interbody Fusion (XLIF) , 2014, Clinical spine surgery.

[16]  R. Fessler,et al.  Surgical site infection rates after minimally invasive spinal surgery. , 2009, Journal of neurosurgery. Spine.

[17]  M. Kønig,et al.  Access related complications in anterior lumbar surgery performed by spinal surgeons , 2013, European Spine Journal.

[18]  A. Herrera,et al.  Clinical outcomes of minimally invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3- to 4-year follow-up , 2013, European Spine Journal.

[19]  N. Anand,et al.  Evidence basis/outcomes in minimally invasive spinal scoliosis surgery. , 2014, Neurosurgery clinics of North America.

[20]  P. Brinckmann,et al.  Interlaminar Shear Stresses and Laminae Separation in a Disc: Finite Element Analysis of the L3‐L4 Motion Segment Subjected to Axial Compressive Loads , 1995, Spine.

[21]  N. Anand,et al.  Limitations and ceiling effects with circumferential minimally invasive correction techniques for adult scoliosis: analysis of radiological outcomes over a 7-year experience. , 2014, Neurosurgical focus.

[22]  Biomechanics of lateral plate and pedicle screw constructs in lumbar spines instrumented at two levels with laterally placed interbody cages. , 2013, The spine journal : official journal of the North American Spine Society.

[23]  J. van Limbeek,et al.  PEEK Cages in Lumbar Fusion: Mid-term Clinical Outcome and Radiological Fusion. , 2012, Journal of spinal disorders & techniques.

[24]  Zachary A. Dooley,et al.  Biomechanical Stability of Lateral Interbody Implants and Supplemental Fixation in a Cadaveric Degenerative Spondylolisthesis Model , 2014, Spine.

[25]  G. Bergmann,et al.  Effect of a pedicle-screw-based motion preservation system on lumbar spine biomechanics: a probabilistic finite element study with subsequent sensitivity analysis. , 2010, Journal of biomechanics.

[26]  N. Abdala,et al.  Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. , 2013, Journal of neurosurgery. Spine.

[27]  Moon-Chan Kim,et al.  Subsidence of Polyetheretherketone Cage After Minimally Invasive Transforaminal Lumbar Interbody Fusion , 2013, Journal of spinal disorders & techniques.

[28]  M. Alimi,et al.  Adult Degenerative Scoliosis with Spinal Stenosis Treated with Stand-Alone Cage via an Extreme Lateral Transpsoas Approach; a Case Report and Literature Review , 2015, The archives of bone and joint surgery.

[29]  Tien V. Le,et al.  Subsidence of Polyetheretherketone Intervertebral Cages in Minimally Invasive Lateral Retroperitoneal Transpsoas Lumbar Interbody Fusion , 2012, Spine.

[30]  C. Schizas,et al.  Lymphocoele: a rare and little known complication of anterior lumbar surgery , 2009, European Spine Journal.

[31]  Zachary J. Tempel,et al.  Impaired bone mineral density as a predictor of graft subsidence following minimally invasive transpsoas lateral lumbar interbody fusion , 2015, European Spine Journal.

[32]  T. Nichols,et al.  In vitro biomechanical comparison of an anterior and anterolateral lumbar plate with posterior fixation following single-level anterior lumbar interbody fusion. , 2007, Journal of neurosurgery. Spine.

[33]  L. Pimenta,et al.  Is the Lateral Transpsoas Approach Feasible for the Treatment of Adult Degenerative Scoliosis? , 2014, Clinical orthopaedics and related research.

[34]  K. Choi,et al.  Biomechanical comparison of anterior lumbar interbody fusion: stand-alone interbody cage versus interbody cage with pedicle screw fixation - a finite element analysis , 2013, BMC Musculoskeletal Disorders.

[35]  B. Ozgur,et al.  Two-year clinical and radiographic success of minimally invasive lateral transpsoas approach for the treatment of degenerative lumbar conditions , 2010, SAS Journal.

[36]  W. Hayes,et al.  The compressive behavior of bone as a two-phase porous structure. , 1977, The Journal of bone and joint surgery. American volume.

[37]  A. Kaye,et al.  Outcomes of extended transforaminal lumbar interbody fusion for lumbar spondylosis , 2015, Journal of Clinical Neuroscience.

[38]  Kai-Ming G. Fu,et al.  Can a Minimal Clinically Important Difference Be Achieved in Elderly Patients with Adult Spinal Deformity Who Undergo Minimally Invasive Spinal Surgery? , 2016, World neurosurgery.

[39]  Robert K. Eastlack,et al.  Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. , 2015, Journal of neurosurgery. Spine.

[40]  J. Jennings,et al.  Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis , 2013, Journal of Clinical Neuroscience.

[41]  Etsuo Chosa,et al.  Effects of lumbar spinal fusion on the other lumbar intervertebral levels (three-dimensional finite element analysis) , 2003, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[42]  B. Cunningham,et al.  The Effect of Spinal Implant Rigidity on Vertebral Bone Density A Canine Mode , 1991, Spine.

[43]  Zachary A. Dooley,et al.  Biomechanics of Lateral Interbody Spacers: Going Wider for Going Stiffer , 2012, TheScientificWorldJournal.

[44]  Jacob R. Joseph,et al.  Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature. , 2015, Neurosurgical focus.

[45]  R. Fessler,et al.  The development of minimally invasive spine surgery. , 2006, Neurosurgery clinics of North America.

[46]  Hao Xu,et al.  Biomechanical Comparison of Transforaminal Lumbar Interbody Fusion With 1 or 2 Cages by Finite-Element Analysis , 2013, Neurosurgery.

[47]  Alexander W. L. Turner,et al.  Biomechanical Analysis and Review of Lateral Lumbar Fusion Constructs , 2010, Spine.

[48]  G. Tender.  Caudal vertebral body fractures following lateral interbody fusion in nonosteoporotic patients. , 2014, The Ochsner journal.