Ahlquist Seth, Thommen Rachel, Park Howard Y, Sheppard William, James Kevin, Lord Elizabeth, Shamie Arya N, Park Don Y
Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA.
J Spine Surg. 2020 Dec;6(4):659-669. doi: 10.21037/jss-20-595.
Anterior lumbar interbody fusion (ALIF) is commonly utilized in lumbar degenerative pathologies. Standalone ALIF (ST-ALIF) systems were developed to avoid added morbidity, surgical time, and cost of anterior and posterior fusion (APF). Controversy exists in the literature about which of these two techniques yields superior clinical and radiographic outcomes, and few studies have directly compared them. This study seeks to compare ST-ALIF and APF in terms of sagittal correction and surgical complications.
Ninty-two consecutive ALIF cases performed from 2013-2018 were retrospectively reviewed and separated into 2 groups. Radiographic measurements were performed on pre- and post-operative radiographs, including segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL). Surgical complications were determined. Statistical analysis was performed using chi-square test of homogeneity, Fisher's exact test, and independent sample t-test. Comparisons between groups were deemed statistically significant at the P<0.05 threshold.
Fifty-seven ST-ALIF, 35 APF were identified. There were no differences in age, gender, BMI, Charlson Comorbidity Index (CCI), preoperative diagnosis, or surgical level between the 2 cohorts. Bone Morphogenetic Protein (BMP) was utilized in 24.6% of ST-ALIF versus none of APF (P=0.001). No differences were detected in SL, LL, and PI-LL mismatch. ST-ALIF cohort had significantly greater risk of subsidence and revision surgery versus APF (12.3% 0%, RD 95% CI: 3.8-20.8%, P=0.042). Recurrent spondylolisthesis occurred in 5 ST-ALIF cases, 3 cases with implant failure, and 2 nonunions versus none in the APF group.
ST-ALIF was associated with significantly greater subsidence and revision surgery versus APF. Careful patient selection is paramount when considering ST-ALIF. The potential for revision surgery may offset the potential benefit in avoiding posterior fusion. Despite the greater risk of subsidence, sagittal alignment was not significantly affected.
腰椎前路椎间融合术（ALIF）常用于治疗腰椎退行性病变。独立的ALIF（ST-ALIF）系统的研发旨在避免前后路联合融合术（APF）所带来的额外发病率、手术时间及费用。关于这两种技术哪种能产生更优的临床和影像学结果，文献中存在争议，且很少有研究对它们进行直接比较。本研究旨在比较ST-ALIF和APF在矢状面矫正和手术并发症方面的差异。
回顾性分析2013年至2018年连续进行的92例ALIF病例，并将其分为两组。对术前和术后的X线片进行影像学测量，包括节段性前凸（SL）、腰椎前凸（LL）和骨盆入射角与腰椎前凸失配（PI-LL）。确定手术并发症。采用卡方同质性检验、Fisher精确检验和独立样本t检验进行统计分析。两组间比较在P<0.05阈值时被认为具有统计学意义。
共识别出57例ST-ALIF和35例APF。两组在年龄、性别、体重指数、Charlson合并症指数（CCI）、术前诊断或手术节段方面无差异。24.6%的ST-ALIF使用了骨形态发生蛋白（BMP），而APF均未使用（P=0.001）。在SL、LL和PI-LL失配方面未检测到差异。与APF相比，ST-ALIF组发生下沉和翻修手术的风险显著更高（12.3%对0%，风险差值95%可信区间：3.8-20.8%，P=0.042）。5例ST-ALIF病例发生复发性椎体滑脱，3例植入物失败，2例骨不连，而APF组无一例发生。
与APF相比，ST-ALIF发生下沉和翻修手术的风险显著更高。考虑ST-ALIF时，仔细选择患者至关重要。翻修手术的可能性可能会抵消避免后路融合的潜在益处。尽管下沉风险更高，但矢状面排列未受到显著影响。
