Anterior Lumbar Interbody Fusion With Cement Augmentation Without Posterior Fixation to Treat Isthmic Spondylolisthesis in an Osteopenic Patient—A Surgical Technique

Abstract

Background: Anterior lumbar interbody fusion (ALIF) has been well established as an effective surgical intervention for chronic back pain due to osteoporotic vertebral collapse. Historically, ALIF has consisted of an anterior approach to disc height restoration with a subsequent posterior pedicle screw fixation. Although the applications of cement augmentation with posterior fixation have been previously reported, treatment of patients with both isthmic spondylolisthesis and decreased bone mineral density using a stand-alone ALIF is controversial because of concerns for decreased fusion rates and increased subsidence risk, respectively. We report a case of stand-alone ALIF used to treat a low-grade isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis in a patient with secondary degenerative changes and discuss the benefits of this surgical technique in a patient with several comorbidities.Methods: An osteopenic 66-year-old woman with multiple medical comorbidities and 2 years of left radicular leg pain was found to have a Myerding grade I isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis with secondary changes. The patient underwent an L5-S1 stand-alone ALIF with anterior cement augmentation without posterior pedicle screw fixation.Results: The patient experienced immediate relief of radicular leg pain postoperatively and had an uneventful course. At 2 years follow-up, she remained symptom free, and radiographs showed excellent fusion and maintenance of intervertebral disc height.Conclusions: The use of stand-alone ALIF with anterior cement augmentation of the vertebral bodies is a surgical technique that could produce excellent improvement in patients with low-grade isthmic spondylolisthesis in the setting of osteopenia. The use of the all-anterior approach in similar patients with multiple medical comorbidities can also be a useful technique, as it decreases associated morbidity of surgery and complication risks associated with prolonged operative times.

Letter to the Editor Regarding Anterior Lumbar Interbody Fusion With Cement Augmentation Without Posterior Fixation to Treat Isthmic Spondylolisthesis in an Osteopenic Patient—A Surgical Technique, by Cyriac et al.

“…The authors present and describe a case with spondylolisthesis at the lumbosacral junction treated with ALIF complemented with PMMA in a patient with scoliosis and osteopenia. 1 In the presented case, the authors do not mention that this is not an L5-S1 level but an L5-transitional vertebra; a rudimentary disc is observed below the treated level, and I believe that this is not only a terminological issue.…”

Diagnostic, Surgical, and Technical Considerations for Lumbar Interbody Fusion in Patients with Osteopenia and Osteoporosis: A Systematic Review

“…Cyriac et al [ 18 ] published a case report on anterior lumbar interbody fusion (ALIF) with cement augmentation without posterior fixation used to treat low-grade isthmic spondylolisthesis in the setting of idiopathic thoracolumbar scoliosis with secondary degenerative changes. The patient was an osteopenic 66-year-old with multiple comorbidities presenting with 2 years of left radicular leg pain who was found to have a Myerding grade I isthmic spondylolisthesis.…”

Impact of bone density and integrated screw configuration on standalone anterior lumbar interbody construct strength

“…Lack of stability has been linked to increased rates of pseudarthrosis, subsidence, and implant failure [ [15] , [16] , [17] ]. While ALIFs supported with additional posterior fixation often provide superior biomechanical stability, they are associated with increased costs, longer operative times, higher perioperative blood loss, and higher postoperative morbidity [ 16 , 5 , 18 , 6 , 19 ]. In addition, the increased dissection necessitated by posterior fixation may increase the risk of implant failure and adjacent-segment disease [ 20 ].…”