Risk factors for intraoperative endplate injury during minimally-invasive lateral lumbar interbody fusion

Abstract

During lateral lumbar interbody fusion (LLIF), unintended intraoperative endplate injury (IEPI) can occur and thereafter lead cage subsidence. The aim of this study was to investigate the incidence of IEPI during LLIF, and its predisposing factors. A retrospective review was conducted on consecutive patients (n = 186; mean age, 70.0 ± 7.6 years) who underwent LLIF at 372 levels. Patient’s demographic and surgical data were compared between patients with and without IEPI. Also, the radiographic data of each level were compared between intact and IEPI segments. IEPI was identified at 76 levels (20.4%) in 65 patients. The incidences of IEPI at every 100 consecutive segments were not different. When 372 segments were analyzed independently, sagittal disc angle (DA) in the extended position (4.3° ± 3.6° at IEPI segments vs. 6.4° ± 4.0° at intact segments), the difference between sagittal DA in the extended position and cage angle (− 2.2° ± 4.0° vs. 0.0° ± 3.9°), and the difference between preoperative disc height and cage height (− 5.4 mm ± 2.4 mm vs. − 4.7 mm ± 2.0 mm) were different significantly. Also, endplate sclerosis was more common at intact segments than IEPI segments (33.2% vs. 17.3%). Multivariate analysis showed that male sex (odds ratio [OR] 0.160; 95% confidence interval [CI] 0.036–0.704), endplate sclerosis (OR 3.307; 95% CI 1.450–8.480), and sagittal DA in the extended position (OR 0.674; 95% CI 0.541–0.840) were significant associated factors for IEPI. IEPI was correlated not with surgeon’s experience, but with patient factors, such as sex, preoperative disc angle, and endplate sclerosis. Careful surgical procedures should be employed for patients with these predisposing factors.

Comparative Study of Cage Subsidence in Single-Level Lateral Lumbar Interbody Fusion

“…The effects of osteoporosis make up a large proportion of patient factors that influence decompression. Kim et al noted that endplate injury might be affected by cortical bone strength [ 12 ]. It has been reported that the endplate cranial to the disc was thicker and of greater density than the caudal disc.…”

“…However, these LLIF procedures can result in several perioperative complications, including nerve injury, vascular injury, or endplate injury [ 3 , 9 , 10 , 11 ]. Among these, endplate injury often occurs during endplate preparation and cage placement [ 12 ]. Once it occurs, it may result in cage subsidence to adjacent vertebral endplates, leading to the loss of segmental lordosis, foraminal height, and postoperative indirect decompression.…”

Analysis of Risk Factors for Adjacent Segment Degeneration after Minimally Invasive Transforaminal Interbody Fusion at Lumbosacral Spine

“…The results of Kanayama et al further discussed clinical symptoms following intervertebral fusion and noted that disc angle in flexion is an important prognostic factor [ 23 ]. Considering the predictive performance of sagittal DA in predicting complications after MIS-TLIF surgery at the L5-S1 level, including a higher DA suggesting a lower fusion rate of the operated segment [ 24 ] and a lower DA being a significant associated factor of intraoperative endplate injury [ 25 ] and fixed flat-back deformity [ 26 ], future studies need to develop individualized models of the corresponding vertebral segment when investigating the triggers of symptomatic ASD. In parallel, the pathological process of ASD requires to be defined precisely in order to preclude the interference of natural degeneration of adjacent vertebrae.…”

Vertebral Endplate Concavity in Lateral Lumbar Interbody Fusion: Tapered 3D-Printed Porous Titanium Cage versus Squared PEEK Cage

“…Unintentional intraoperative endplate injuries in XLIF have been identified in 10.4% to 20.4% of cases [ 4 , 5 ]. The vertebral endplate injuries were not correlated with surgical experience but rather with patient factors, such as older age, female gender, low bone density, preoperative disc angle, and vertebral endplate stiffening, as well as cage height [ 2 , 4 , 5 ].…”