Multilevel Anterior Lumbar Interbody Fusion Combined with Posterior Stabilization in Lumbar Disc Disease- Prospective Analysis of Clinical and Functional Outcomes

Moura, Diogo Lino; Lawrence, David; Gabriel, Josué Pereira

doi:10.1016/j.rbo.2017.11.006

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Sumário

Original Article • Rev. bras. ortop. 54 (02) • Mar-Apr 2019 • https://doi.org/10.1016/j.rbo.2017.11.006 copy

Multilevel Anterior Lumbar Interbody Fusion Combined with Posterior Stabilization in Lumbar Disc Disease- Prospective Analysis of Clinical and Functional Outcomes^* * Work developed at the Serviço de Ortopedia of the Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

This was a prospective controlled study with lumbar degenerative disc disease patients submitted to instrumented anterior lumbar interbody fusion (ALIF) combined with posterior stabilization.

Methods

A sample with 64 consecutive patients was operated by the same surgeons over 4 years. Half of the ALIFs occurred at 2 levels, 43.8% at 3 levels, and 6.25% at 1 level. Interbody cages with integrated screws, filled with bone matrix and bone morphogenetic protein 2, were used.

Results

Half of the patients had undergone previous lumbar spine surgeries, 75% presented with associated degenerative listhesis, and 62.5% had posterior lumbar compression disease. Approximately 56% of the sample had at least 1 risk factor for nonunion. The Oswestry index changed from 71.81 ± 7.22 at the preoperative assessment to 24.75 ± 7.82 at the final follow-up evaluation, while the visual analogue pain scale changed from 7.88 ± 0.70 to 2.44 ± 0.87 (p < 0.001). Clinical and functional improvements increased with the number of operated levels, proving the efficacy of multilevel ALIF, performed in 93.75% of the sample. The global complication rate was of 7.82%, with no major complications. No cases of nonunion were observed.

Conclusion

Instrumented ALIF combined with posterior stabilization is a successful option for uni- and multilevel degenerative disc disease of the L3 to S1 segments, even in the significant presence of risk factors for nonunion and of previous lumbar surgeries, assuring very satisfactory clinical-functional and radiographic outcomes with a low medium-term complication rate.

Keywords:
lumbar vertebrae/ surgery; spinal fusion; prospective studies; scoliosis/surgery; risk factors

Therapeutic protocol
Approach route	Lumbar spine retroperitoneal abdominal anterior route
Number of operated levels	According to the presence of degenerative disc disease, listhesis and need of lumbar lordosis repair
Interbody cages	Anatomical, lordotic, with notches and optional screw integration through the implant. Cages are made of polyetheretherketone (PEEK)
Cage filling	Demineralized bone material and absorbable collagen plaque with human recombinant bone morphogenetic protein (BMP-2) (Infuse [Medtronic]®)
Cage fixation	Cages are fixed with three screws, two at the inferior vertebral body and one in the superior vertebral body

Parameters	Mean and standard deviation values
Age	53.63 ± 9.47 years old
Mean ALIF time	105.63 ± 24.49 minutes
Blood loss during ALIF	96.88 ± 60.99 mL
ALIF-related hospitalization time	4.25 ± 0.98 days

	Preoperative Oswestry index	Final Oswestry index	Mean Oswestry index reduction	Preoperative visual analogue pain scale	Final visual analogue pain scale	Mean visual analogue pain scale reduction
With risk factors	75.44 ± 5.92	30.22 ± 3.85	45.22 ± 5.23	8.11 ± 0.75	2.89 ± 0.57	5.22 ± 0.42
Without risk factors	67.14 ± 6.00	17.71 ± 5.68	49.43 ± 4.42	7.57 ± 0.50	1.86 ± 0.85	5.71 ± 0.71
p-value	< 0.001^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.003^a P values with statistical significance.	0.03^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.002^a P values with statistical significance.
Obese patients	77.00 ± 5.16	30.71 ± 2.35	46.29 ± 5.44	8.14 ± 0.65	2.86 ± 0.36	5.29 ± 0.46
Nonobese patients	67.78 ± 5.91	20.11 ± 7.43	47.67 ± 5.17	7.67 ± 0.68	2.11 ± 1.01	5.56 ± 0.69
p-value	< 0.001^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.384	0.007^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.127
Smokers	75.00 ± 7.30	29.75 ± 4.97	45.25 ± 4.97	8.00 ± 0.73	3.00 ± 0.73	5.00
Nonsmokers	70.75 ± 6.94	23.08 ± 7.92	47.67 ± 5.30	7.83 ± 0.69	2.25 ± 0.84	5.58 ± 0.65
p-value	0.043^a P values with statistical significance.	0.002^a P values with statistical significance.	0.17	0.416	0.005^a P values with statistical significance.	< 0.001^a P values with statistical significance.
Diabetic patients	80.67 ± 4.38	31.33 ± 0.98	49.33 ± 3.45	8.33 ± 0.49	3.00	5.33 ± 0.49
Nondiabetic patients	69.77 ± 6.12	23.23 ± 7.92	46.54 ± 5.53	7.77 ± 0.70	2.31 ± 0.92	5.46 ± 0.64
p-value	< 0.001^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.097	0.011^a P values with statistical significance.	0.007^a P values with statistical significance.	0.628
Primary surgery	68.13 ± 8.01	19.63 ± 7.53	48.50 ± 5.05	7.50 ± 0.51	1.88 ± 0.79	5.63 ± 0.71
Previous spinal surgeries	75.50 ± 3.70	29.88 ± 3.64	45.63 ± 5.20	8.25 ± 0.67	3.00 ± 0.51	5.25 ± 0.44
p-value	< 0.001^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.013^a P values with statistical significance.	< 0.001^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.023^a P values with statistical significance.
With neurological deficits	74.40 ± 6.44	25.20 ± 7.06	49.20 ± 3.97	8.20 ± 0.77	2.40 ± 0.82	5.80 ± 0.77
Without neurological deficits	70.64 ± 7.31	24.55 ± 8.21	46.09 ± 5.56	7.72 ± 0.62	2.45 ± 0.90	5.27 ± 0.45
p-value	0.907	0.058	0.062	0.016^a P values with statistical significance.	0.900	0.004^a P values with statistical significance.
With posterior compression	73.90 ± 7.31	25.30 ± 8.63	48.60 ± 5.48	8.20 ± 0.61	2.60 ± 0.93	5.60 ± 0.67
Without posterior compression	68.33 ± 5.65	23.83 ± 6.31	44.50 ± 3.86	7.33 ± 0.48	2.17 ± 0.71	5.17 ± 0.38
p-value	0.003^a P values with statistical significance.	0.315	0.002^a P values with statistical significance.	< 0.001^a P values with statistical significance.	0.022^a P values with statistical significance.	0.006^a P values with statistical significance.

Number of operated levels	Average improvement in clinical and functional scores
Number of operated levels	Oswestry index	Visual analogue pain scale
1	40.00 ± 1.11	5.00 ± 1.12
2	46.13 ± 5.53	5.25 ± 0.44
3	49.14 ± 4.16	5.71 ± 0.71

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E-mail: rbo@sbot.org.br

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[1] Address for correspondence
Diogo Lino Moura, Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal (e-mail: dflmoura@gmail.com).

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Multilevel Anterior Lumbar Interbody Fusion Combined with Posterior Stabilization in Lumbar Disc Disease- Prospective Analysis of Clinical and Functional Outcomes* * Work developed at the Serviço de Ortopedia of the Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Abstract

Objective

Methods

Results

Conclusion

Multilevel Anterior Lumbar Interbody Fusion Combined with Posterior Stabilization in Lumbar Disc Disease- Prospective Analysis of Clinical and Functional Outcomes^* * Work developed at the Serviço de Ortopedia of the Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.