Influence of Cage Design on Radiological and Clinical Outcomes in Dorsal Lumbar Spinal Fusions: A Comparison of Lordotic and Non-Lordotic Cages.

OBJECTIVES

To evaluate the comparison between lordotic and non-lordotic transforaminal lumbar interbody fusion (TLIF) cages in degenerative lumbar spine surgery and analyze radiological as well as clinical outcome parameters in long-term follow up.

METHODS

In a retrospective study design, we compared 37 patients with non-lordotic cage (NL-group) and 40 with a 5° lordotic cage (L-group) implanted mono- or bi-segmental in TLIF-technique from 2013 to 2016 and analyzed radiological parameters of pre- and postoperative (Lumbar lordosis (LL), segmental lordosis (SL), and pelvic tilt (PT), as well as clinical parameters in a follow-up physical examination using the Oswestry disability index (ODI), Roland-Morris Score (RMS), and visual analog scale (VAS).

RESULTS

Surgery was mainly performed in lower lumbar spine with a peak in L4/5 (mono-segmental) and L4 to S1 (bi-segmental), long-term follow-up was on average 4 years postoperative. According to the literature, we found significantly better results in radiological outcome in the L-group compared to the NL-group: LL increased 6° in L-group (51° preoperative to 57° postoperative) and decreased 1° in NL-group (50° to 49° (P < 0.001). Regarding SL, we found an increase of 5° in L-group (13° to 18°) and no difference in NL-group (15°)(P < 0.001). In PT, we found a clear benefit with a decrease of 2° in L-group (21° to 19°) and no difference in NL-group (P = 0.008). In direct group comparison, ODI in NL-group was 23% vs 28% in L-group (P = 0.25), RMS in NL-group was 8 points vs 9 points in L-group (P = 0.48), and VAS was in NL-group 2.7 vs 3.2 in L-group (P = 0.27) without significant differences. However, the clinical outcome in multivariate analysis indicated a significant multivariate influence across ODI and RMS of BMI (Wilks λ = 0.57, F [4, 44] = 3.61, P = 0.012) and preoperative SS (Wilks λ = 0.66, F [4, 44] = 2.54, P = 0.048). Age, gender, cage type and postoperative PT had no significant influence (P > 0.05). Intraoperatively, we saw three dura injuries that could be sutured without problems and had no consequences for the patient. In the follow-up, we did not find any material-related problems, such as broken screws or cage loosening, also no pseudarthrosis.

CONCLUSION

In conclusion, we think it's not cage design but other influenceable factors such as correct indication and adequate decompression that lead to surgical success and the minimal difference in the LL therefore seemed to be of subordinate importance.