A Comparative Biomechanical Investigation of Anterior Lumbar Interbody Cages: Central and Bilateral Approaches*

Oxland, Thomas R.; Hoffer, Zoltán; Nydegger, Thomas; Ráthonyi, Gábor K.; Nolte, L.-P.

doi:10.2106/00004623-200003000-00009

Cited by 70 publications

(56 citation statements)

References 23 publications

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“…But we found Blumenthal's study [3] to be highly influential to the overall results in sensitivity analysis, which reported good function result and significantly higher patient satisfaction rate in TDR group compared with BAK cage interbody fusion. Because stand-alone interbody cages have limitations in biomechanical properties such as inadequate stabilization and subsidence [13,38,40], ALIF with BAK cage may overestimate the effect of compared TDR. After omitting Blumenthal's study, there is no longer significant difference in function and pain status and patient satisfaction between TDR and fusion group.…”

Section: Discussionmentioning

confidence: 99%

A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease

Zhu

Han

et al. 2010

Eur Spine J

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Lumbar fusion has been developed for several decades and became the standard surgical treatment for symptomatic lumbar degenerative disc disease (DDD). Artificial total disc replacement (TDR), as an alternative for spinal arthrodesis, is becoming more commonly employed treating lumbar DDD. It is still uncertain whether TDR is more effective and safer than lumbar fusion. To systematically compare the effectiveness and safety of TDR to that of the fusion for the treatment of lumbar DDD, we performed a meta-analysis. Cochrane review methods were used to analyze all relevant randomized controlled trials published up to July 2009. Five relevant randomized controlled trials involving 837 patients were identified. Patients in TDR group have sightly better functioning and less back or leg pain without clinical significance, and significantly higher satisfaction status in TDR group compared with lumbar fusion group at the 2-year followup. But these outcomes are highly influenced by the study with BAK cage interbody fusion, the function/pain and patient satisfaction status are no longer significantly different between two groups after excluding this study. At 5 years, these outcomes are not significantly different between comparing groups. The complication and reoperation rate of two groups are similar both at 2 and at 5 years. In conclusion, TDR does not show significant superiority for the treatment of lumbar DDD compared with fusion. The benefits of motion preservation and the long-term complications are still unable to be concluded. More highquality RCTs with long-term follow-up are needed.

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Section: Discussionmentioning

confidence: 99%

A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease

Zhu

Han

et al. 2010

Eur Spine J

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“…Experimental studies have been done using animal and human cadaver models. The influence of implant design, additional posterior instrumentation, surgical approach and bone mineral density on stiffness, compressive strength and three-dimensional flexibility under static, quasi-static and cyclic loading have been investigated [11,14,15,20,27,28,29,38,40,43]. Summarising their review of biomechanical cage studies on human specimens, Oxland and Lund stated that the anterior approach produced better initial stability than the posterior one, that adding a posterior fixation creates the most stable construct, and that vertebral bone density played a very important role for the compressive strength of the interface between cage and vertebra [27].…”

Section: Introductionmentioning

confidence: 99%

Factors influencing stresses in the lumbar spine after the insertion of intervertebral cages: finite element analysis

et al. 2002

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IntroductionIntervertebral cages in the lumbar spine have been a promising advancement in spinal fusion. The final goal of the procedure is to relieve low back pain, one of today's major and most expensive health care problems. A large number of cages exist, which are different in design, material and surgical implanting approach. Several clinical follow-up studies have been published, mostly reporting high fusion rates, even though the criteria for success are inconsistent [1,5,17,18,23,25,30,31]. Additionally, there have been reports of mechanical failure, subsidence and migration [23,39,42]. The success of a cage insertion, which is regarded as fusion, and thereby stabilisation, of the spine, in addition to the biological factors, may be dependent on other parameters, including material properties of the vertebrae or the cage, geometry of the implant, and the interface between the bone and the cage [23,25,39,43].Hence, experimental and finite element studies have been carried out to investigate the influence of these facAbstract Intervertebral cages in the lumbar spine have been an advancement in spinal fusion to relieve low back pain. Even though initial stability is accepted as a requirement for fusion, there are other factors. The load transfer and its effect on the tissues adjacent to the cage may also play an essential role, which is not easily detectable with experimental tests. In this study the effects of an intervertebral cage insertion on a lumbar functional spinal unit were investigated using finite element analyses. The influences of cage material, cancellous bone density and spinal loading for the stresses in a functional spinal unit were evaluated. Three-dimensional (3D) finite element models of L2-L3 were developed for this purpose. An anterior approach for a monobloc, boxshaped cage was modelled. Models with cage were compared to the corresponding intact ones. The results showed that inserting a cage increased the maximum von Mises stress and changed the load transfer in the adjacent structures. Varying the cage material or the loading conditions had a much smaller influence than varying the cancellous bone density. The denser the cancellous bone, the more the stress was concentrated underneath the cage, while the remaining regions were unloaded. This study showed that the density of the underlying cancellous bone is a more important factor for the biomechanical behaviour of a motion segment stabilized with a cage, and its eventual clinical success, than the cage material or the applied load. Inserting an intervertebral cage markedly changed the load transfer. The altered stress distribution may trigger bone remodelling and explain damage of the underlying vertebrae.

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“…17 Nonetheless, a number of biomechanical analyses have questioned the adequacy of ALIF cages in terms of stability. 11,21,23 Next-generation designs have thus integrated a fixation plate to secure the distraction cage anteriorly. These devices now offer stability comparable to that conferred by posterior fixation, without need of posterior access.…”

mentioning

confidence: 99%

Fracture of the L-4 vertebral body after use of a stand-alone interbody fusion device in degenerative spondylolisthesis for anterior L3–4 fixation

Y¹,

Jang

Lee³

et al. 2014

SPI

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Many studies attest to the excellent results achieved using anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. The purpose of this report is to document a rare instance of L-4 vertebral body fracture following use of a stand-alone interbody fusion device for L3–4 ALIF. The patient, a 55-year-old man, had suffered intractable pain of the back, right buttock, and left leg for several weeks. Initial radiographs showed Grade I degenerative spondylolisthesis, with instability in the sagittal plane (upon 15° rotation) and stenosis of central and both lateral recesses at the L3–4 level. Anterior lumbar interbody fusion of the affected vertebrae was subsequently conducted using a stand-alone cage/plate system. Postoperatively, the severity of spondylolisthesis diminished, with resolution of symptoms. However, the patient returned 2 months later with both leg weakness and back pain. Plain radiographs and CT indicated device failure due to anterior fracture of the L-4 vertebral body, and the spondylolisthesis had recurred. At this point, bilateral facetectomies were performed, with reduction/fixation of L3–4 by pedicle screws. Again, degenerative spondylolisthesis improved postsurgically and symptoms eased, with eventual healing of the vertebral body fracture. This report documents a rare instance of L-4 vertebral body fracture following use of a stand-alone device for ALIF at L3–4, likely as a consequence of angular instability in degenerative spondylolisthesis. Under such conditions, additional pedicle screw fixation is advised.

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A Comparative Biomechanical Investigation of Anterior Lumbar Interbody Cages: Central and Bilateral Approaches*

Cited by 70 publications

References 23 publications

A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease

A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease

Factors influencing stresses in the lumbar spine after the insertion of intervertebral cages: finite element analysis

Fracture of the L-4 vertebral body after use of a stand-alone interbody fusion device in degenerative spondylolisthesis for anterior L3–4 fixation

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