Surgical Strategies for the Treatment of Lumbar Pseudarthrosis in Degenerative Spine Surgery: A Literature Review and Case Study

Abstract

Background Pseudarthrosis after lumbar fusion can generate pain and disability and often requires revision. However, results of revision procedures have historically been relatively poor. Questions/Purpose The aim of this review was to examine the current evidence related to the management of lumbar pseudarthrosis, with a focus on revision after failure of posterolateral fusion or lumbar interbody fusion. Methods A review of orthopedic spine literature published before March 2019 was conducted using PubMed and Google Scholar. Studies addressing revision after failed posterolateral fusions and after failed interbody fusion were selected. We also present a case of successful revision after failed transforaminal lumbar interbody fusion (TLIF). Results The review revealed that persistent pseudarthrosis after revision posterolateral fusion occurs at rates of 35 to 51%. No significant difference has been demonstrated in rates of successful fusion after anterior lumbar interbody fusion (ALIF) and ALIF with revision posterolateral fusion for pseudarthroses after failed TLIF procedures (81% versus 88%), although ALIF alone may be appealing because it avoids further disruption of the posterior musculature. No significant differences have been observed in quality-of-life scores among patients undergoing revision after posterolateral fusion, TLIF, ALIF, or ALIF with posterior fusion. Failed TLIF cages may be extracted and replaced through an anterior or lateral approach. If the geometry of the failed cage permits insertion of a second cage, a contralateral approach may be used. Revision retroperitoneal approaches are associated with higher complication rates. Conclusions The management of lumbar pseudarthrosis requires careful planning, as well as intra-operative attention to detail, for revision surgery to be successful. Circumferential procedures have shown success in revision posterolateral and interbody fusion failures.

Discoplasty as a salvage technique for pseudoarthrosis following multilevel TLIFS: A case report

“…Despite its relatively high prevalence, there is a lack of robust clinical evidence on salvage option for lumbar pseudoarthrosis. Several previous studies have reported ALIF as a useful and safe procedure for treating failed PLIF or TLIF with not only in radiographic improvements in bony fusion, but also in significant improvements in the patient's physical and mental experience of pain [1] , [2] , [6] .…”

“…Pseudoarthrosis, often defined as a failure to achieve osseous fusion by the 1-year post-operative time point [6] . Pseudoarthrosis usually determined by the presence of persistent motion and absence of mature traversing bony trabeculae between the vertebral bodies used.…”

Twenty-four-month interim results from a prospective clinical trial evaluating the performance and safety of a cellular bone allograft in patients undergoing lumbar spinal fusion

“…Fusion success and clinical outcomes may be affected by patient risk factors for pseudoarthrosis, including older age, osteoporosis, alcoholism, malnutrition, and smoking [29][30][31] . In this study, we analyzed subsets of patients with known risk factors for nonunion and found the fusion rates not signi cantly different between patients with a single risk factor or multiple risk factors.…”

Indolent Infection After Lumbar Interbody Fusion: An Under-recognized Cause of Pseudarthrosis, Which Can Be Successfully Treated With Anterior Revision Fusion

“…1,2 Pseudarthrosis, a failure of adequate fusion between adjacent vertebral bodies, is a complication seen in 2.6% to 15% of initial posterior fusion procedures, with reoccurrence reported in up to 51% of patients after revision surgery. 3,4 Patient-related risk factors for pseudarthrosis include diabetes, use of steroids or nonsteroidal antiinflammatory drugs, and smoking. 5 However, recent reports have described infection as a common etiology for pseudarthrosis, particularly Cutibacterium acnes (C acnes) and coagulase-negative Staphylococcus (CoNS).…”

“…1,2 Pseudarthrosis, a failure of adequate fusion between adjacent vertebral bodies, is a complication seen in 2.6% to 15% of initial posterior fusion procedures, with reoccurrence reported in up to 51% of patients after revision surgery. 3,4…”