Cage positioning as a risk factor for posterior cage migration following transforaminal lumbar interbody fusion – an analysis of 953 cases

Abstract

Background The risk of posterior cage migration (PCM) exists when a fusion cage is used for transforaminal lumbar interbody fusion (TLIF). This complication is influenced by contact pressure between the endplate and the cage. Previous reports demonstrated that anteriorly located cages bore more load and had greater strain than posteriorly located cages. However, there have been no detailed reports on the correlation between cage positioning and PCM. Methods From March 2014 to October 2015, we reviewed 953 patients receiving open transforaminal lumbar interbody fusion (TLIF) and bilateral pedicle screw instrumentation. One hundred patients without PCM were randomly sampled as the control group. Postoperative sagittal and coronal cage positions in the disc space were evaluated with the ‘depth ratio’ and the ‘coronal ratio’. The demographic data of patients with and without PCM were compared to detect patient-related factors. Radiographic and cage related parameters, including cage position, preoperative disc height, preoperative spine stability, cage geometry, cage size, and height variance (= cage height – preoperative disc height) were compared between the PCM group and the control group. Univariate analyses and a multivariate logistic model were used to identify risk factors of PCM. Results Posterior cage migration occurred in 24 (2.52%) of 953 patients. The univariate and multivariate analyses revealed that those with a decreased depth ratio (OR, 9.78E-4; 95% CI, 9.69E-4 – 9.87E-4; p < 0.001) and height variance (OR, 0.757, 95% CI, 0.575–0997, p = 0.048) had a significantly higher risk of developing PCM. Conclusions Our results verified that posteriorly located cages and undersized cages are more prone to developing PCM, which may aid surgeons in making optimal decisions during TLIF procedures.

Endplate injury as a risk factor for cage retropulsion following transforaminal lumbar interbody fusion

“…Park et al [ 3 ] also reported that posterior cage positioning was a significant factor for CR. Here, we used quantitative measurements introduced by Hu et al [ 8 ] to evaluate cage positioning. In accordance with their results, [ 8 ] we found that sagittal, but not coronal cage positioning was correlated with CR.…”

“…Here, we used quantitative measurements introduced by Hu et al [ 8 ] to evaluate cage positioning. In accordance with their results, [ 8 ] we found that sagittal, but not coronal cage positioning was correlated with CR. Biomechanical studies demonstrated that constructs with anterior cage placement were significantly stiffer than those with posterior cage placement, and that the cage shared more load under axial compression with anterior cage placement than with posterior cage placement.…”

“…[ 18 ] Second, it could cause inappropriate cage placement, which decreased the axial pressure distributed on the cage and generated less friction to resist posterior cage migration. [ 8 ] Third, the injury involving the posterior cranial endplate on the decompressed side provided a wide passage to facilitate CR.…”

Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies

“…The fusion stability is critically affected by suitable positioning of the pedicle screw [ 12 ], and therefore, continuous effort is being made to improve screw design. The selection and placement of the interbody cage material also impacts the stability and efficacy of TLIF [ 13 , 14 , 15 ]. Progresses have been made to improve the surgical procedure, materials, and instrument to reduce the length of stay and radiation exposure during MIS-TLIF, as prolonged exposure may adversely affect patient’s health and recovery time [ 12 ].…”

Zina percutaneous screw fixation combined with endoscopic lumbar intervertebral fusion under intraoperative neuromonitoring: a technique note report

“…In addition, the decompression of dura and the nerve root was performed under endoscope and INM, avoiding nerve injury and improving the safety of operation.Literature reports suggest that smaller fusion cages must be used when endoscope-guided intrabody cages are placed, because traditional fusion cages are too large to pass through working channels[5,16]. However, the undersized cage may directly cause cage migration into the intervertebral foramen or spinal canal, thus leading to neurological compromise, failure of fixation, or even revision operation[17,18]. The ZELIF technology uses a specially designed C-shaped open channel, which can realize the installation of conventional cages under fluoroscopy without size reduction.…”