Lumbar interbody fusion (LIF) is a treatment option for low back pain secondary to lumbar instability and/or deformity. This review highlights recent studies of surgical techniques and bone healing strategies for LIF. Relevant articles were identified by searching the PubMed database from January 1948 to April 2020, with a focus on the last 5 years, using the following keywords: LIF approach, LIF cage, stem cells for LIF, biomaterials for LIF, and osteobiologics for LIF. LIF procedures were traditionally performed through either a posterior approach (PLIF), or an anterior approach. Later, the transforaminal LIF approach gained popularity over the PLIF as it entailed less nerve retraction. To minimize paraspinal muscle dissections, alternative approaches including lateral LIF, oblique LIF, and minimally invasive approaches have been developed and utilized. These modifications have improved the surgical outcomes of LIF. However, the most recent rates of non-union after LIF procedures still ranged from 7 to 20% with an even higher incidence in patients with osteoporosis. This review summarizes the advantages and disadvantages of each surgical approach and current efforts to enhance LIF by improving fusion cage material properties and developing novel osteobiologic products that contain nanomaterials for controlled release of effective osteogenic proteins and mesenchymal stem cells. There have been significant advances in surgical technologies for LIF over the past decades. Post-operative non-union remains a major challenge, which could be addressed by development of more effective surgical techniques, fusion cages, and bone healing products through joint efforts from spine surgeons, bone biologists, and material engineers.

Lumbar interbody fusion: recent advances in surgical techniques and bone healing strategies

Our study aimed to evaluate differences in outcomes of patients submitted to spinal fusion using different grafts measuring the effectiveness of spinal fusion rates, pseudarthrosis rates, and adverse events. Applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, this systematic review and meta-analysis identified 64 eligible articles. The main inclusion criteria were adult patients that were submitted to spinal fusion, autologous iliac crest (AIC), allograft (ALG), alloplastic (ALP; hydroxyapatite, rhBMP-2, rhBMP-7, or the association between them), and local bone (LB), whether in addition to metallic implants or not, was applied. We made a comparison among those groups to evaluate the presence of differences in outcomes, such as fusion rate, hospital stay, follow-up extension (6, 12, 24, and 48 months), pseudarthrosis rate, and adverse events. Sixty-four studies were identified. LB presented significantly higher proportions of fusion rates (95.3% CI 89.7-98.7) compared to the AIC (88.6% CI 84.8-91.9), ALG (87.8% CI 80.8-93.4), and ALP (85.8% CI 75.7-93.5) study groups. Pseudarthrosis presented at a significantly lower pooled proportion of ALG studies (4.8% CI 0.1-15.7) compared to AIC (8.6% CI 4.2-14.2), ALP (7.1% CI 0.9-18.2), and LB (10.3% CI 1.8-24.5). ALP and AIC studies described significantly more cases of adverse events (80 events/404 patients and 860 events/2001 patients, respectively) compared to LB (20 events/311 patients) and ALG (73 events/459 patients). Most studies presented high risk-of-bias scores. Based on fusion rates and adverse events proportions, LB showed a superior trend among the graft cases we analyzed. However, our review revealed highly heterogeneous data and a need for more rigorous studies to better address and assist surgeons' choices of the best spinal grafts. 

/pdf/a-systematic-review-and-meta-analysis-of-fusion-rate-2elbmpok.pdf

A systematic review and meta-analysis of fusion rate enhancements and bone graft options for spine surgery

Lumbar interbody fusion (LIF) is an established surgical intervention for patients with leg and back pain secondary to disc herniation or degeneration. Interbody fusion involves removal of the herniated or degenerated disc and insertion of interbody devices with bone grafts into the remaining cavity. Extensive research has been conducted on operative complications such as a failure of fusion or non-union of the vertebral bodies. Multiple factors including surgical, implant, and patient factors influencing the rate of complications have been identified. Patient factors include age, sex, osteoporosis, and patient anatomy. Complications can also be influenced by the interbody cage design. The geometry of the bony endplates as well as their corresponding material properties guides the design of interbody cages, which vary considerably across patients with spinal disorders. However, studies on the effects of such variations on the rate of complications are limited. Therefore, this study aimed to perform a systematic review of lumbar endplate geometry and material property factors in LIF failure.Search keywords included 'factor/cause for spinal fusion failure/cage subsidence/cage migration/non-union', 'lumbar', and 'interbody' in electronic databases PubMed and Scopus with no limits on year of publication.In total, 1341 articles were reviewed, and 29 articles were deemed suitable for inclusion. Adverse events after LIF, such as cage subsidence, cage migration, and non-union, resulted in fusion failure; hence, risk factors for adverse events after LIF, notably those associated with lumbar endplate geometry and material properties, were also associated with fusion failure. Those risk factors were associated with shape, concavity, bone mineral density and stiffness of endplate, segmental disc angle, and intervertebral disc height.This review demonstrated that decreased contact areas between the cage and endplate, thin and weak bony endplate as well as spinal diseases such as spondylolisthesis and osteoporosis are important causes of adverse events after LIF. These findings will facilitate the selection and design of LIF cages, including customised implants based on patient endplate properties. 

/pdf/influence-of-the-geometric-and-material-properties-of-lumbar-1uo9zp2z.pdf

Influence of the geometric and material properties of lumbar endplate on lumbar interbody fusion failure: a systematic review

GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature.

Study Design:Retrospective case-control study.Objectives:This study aims to present the clinical and radiographical outcomes of the titanium-polyetheretherketone (Ti/PEEK) composite cage compared t...

https://journals.sagepub.com/doi/pdf/10.1177/21925682211000323

Outcome of Ti/PEEK Versus PEEK Cages in Minimally Invasive Transforaminal Lumbar Interbody Fusion:

The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92–95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ2 = 271.4, df = 72, p < 0.001; I2 = 73.5%, τ2 = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.

Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review

We aim at analysing the impact of anterior lumbar interbody fusion (ALIF) in restoring the main spinopelvic parameters, along with its potentials and limitations in correcting sagittal imbalance. The 2009 PRISMA flow chart was used to systematically review the literature; 27 papers were eventually selected. The following spinopelvic parameters were observed: pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), segmental lumbar lordosis (LLseg) and sagittal vertical axis (SVA). Papers reporting on hyperlordotic cages (HLC) were analysed separately. The indirect decompression potential of ALIF was also assessed. The clinical outcome was obtained by collecting visual analogue scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) scores. Global fusion rate and main complications were collected. PT, SS, LL, LLseg and SVA spinopelvic parameters all improved postoperatively by − 4.3 ± 5.2°, 3.9 ± 4.5°, 10.6 ± 12.5°, 6.7 ± 3.5° and 51.1 ± 44.8 mm, respectively. HLC were statistically more effective in restoring LL and LLseg (p < 0.05). Postoperative disc height, anterior disc height, posterior disc height and foraminal height, respectively, increased by 58.5%, 87.2%, 80.9% and 18.1%. Postoperative improvements were observed in VAS back and leg and ODI scores (p < 0.05). The global fusion rate was 94.5 ± 5.5%; the overall complication rate was 13%. When managing sagittal imbalance, ALIF can be considered as a valid technique to achieve the correct spinopelvic parameters based on preoperative planning. This technique permits to obtain an optimal LL distribution and a solid anterior column support, with lower complications and higher fusion rates when compared to posterior osteotomies.

ALIF in the correction of spinal sagittal misalignment. A systematic review of literature.

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Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review

ALIF in the correction of spinal sagittal misalignment. A systematic review of literature.