Are stand‐alone cages sufficient for anterior lumbar interbody fusion?

Abstract

Anterior lumbar interbody fusion (ALIF) has increased in popularity because it has advantages over posterior fusion. Because there is disagreement about the stability of stand-alone cage ALIF, some surgeons use various types of supplementary fixation, including anterior plates, pedicle screw systems and translaminar screws, to increase segmental stability. Many factors associated with both the cages and endplates influence the time of onset and extent of subsidence after use of stand-alone cage ALIF. A large round cage with an adequate central opening is recommended to facilitate maximum contact with the periphery of the endplate. With regard to the relationship between radiographic fusion and recurrence of symptoms with the development of subsidence, most researchers have reported finding no correlation. Subsidence may be due to a process of bone incorporation between cages and endplates. Does subsidence or nonfusion really matter clinically? Further prospective, randomized controlled trials are very much needed to answer these questions.

The role of sacral slope in lumbosacral fusion: a biomechanical study

“…As described previously, the lumbosacral junction has a larger range of motion than any other lumbar segment. 32,42 It was believed that axial stiffness would be minimal when compared with the constructs. The authors believe that this is due to the angle of L-5 with respect to S-1-which is generally higher than any other lumbar segment.…”

Complex regional pain syndrome following lateral lumbar interbody fusion

“…Recent literature on ALIF suggests a lack of consensus for or against the use of a stand-alone interbody cage for minor symptomatic listhesis. 31 Marchi et al 18 report the use of the LLIF procedure as a surgical option specifically for listhesis. In the authors' experience, LLIF achieves similar outcomes to the ALIF procedure with markedly diminished morbidity and shorter hospital stays compared with both the ALIF and posterior interbody techniques, such as transforaminal lumbar interbody fusion.…”

The importance of loading the periphery of the vertebral endplate

“…It is generally known that the bony periphery of the vertebral endplate possess greater compressive strength and stability than the central region (2)(3)(4)(5)(6)(7). However, mass produced implants (MPIs) are not guaranteed to load the bony periphery of the endplate to provide optimum strength and stability.…”

“…However, mass produced implants (MPIs) are not guaranteed to load the bony periphery of the endplate to provide optimum strength and stability. Indeed, anatomical access is always limited by the size of the portal created in the annulus fibrosis of the disc (6). Therefore, positioning the MPIs in the central region of the endplate is typically a less complicated procedure than ensuring that the endplate periphery is loaded, making this a common scenario (5).…”

“…Therefore, positioning the MPIs in the central region of the endplate is typically a less complicated procedure than ensuring that the endplate periphery is loaded, making this a common scenario (5). Supplemental fixation, either anteriorly, posteriorly or both is often used to provide the required stability (6,8).…”