Risk factors of instrumentation failure and pseudarthrosis after stand-alone L5-S1 anterior lumbar interbody fusion: a retrospective cohort study

Abstract

Objective: L5-S1 stand-alone anterior lumbar interbody fusion (ALIF) is a reliable technique to treat symptomatic degenerative disc disease but remains controversial for treatment of isthmic spondylolisthesis. In the present study the authors aimed to identify risk factors of instrumentation failure and pseudarthrosis after stand-alone L5-S1 ALIF and to evaluate whether instrumentation failure influenced the rate of fusion.

Methods: The study included 64 patients (22 [34.4%] male and 42 [65.6%] female, mean age 46.4 years [range 21-65 years]) undergoing stand-alone L5-S1 ALIF using radiolucent anterior cages with Vertebridge plating fixation in each vertebral endplate. Clinical and radiographic data were reviewed, including age, sex, pelvic parameters, segmental sagittal angle (SSA), C7/sacro-femoral distance (SFD) ratio, C7 sagittal tilt, lumbar lordosis (LL), segmental LL, percentage of L5 slippage, L5-S1 disc angle, and posterior disc height ratio. Univariate and multivariate analyses were used to identify risk factors of instrumentation failure and pseudarthrosis.

Results: At a mean follow-up of 15.9 months (range 6.6-27.4 months), fusion had occurred in 57 patients (89.1%). Instrumentation failure was found in 12 patients (18.8%) and pseudarthrosis in 7 patients (10.9%). The following parameters influenced the occurrence of instrumentation failure: presence of isthmic spondylolisthesis (p < 0.001), spondylolisthesis grade (p < 0.001), use of an iliac crest bone autograft (p = 0.04), cage height (p = 0.03), pelvic incidence (PI) (p < 0.001), sacral slope (SS) (p < 0.001), SSA (p = 0.003), and LL (p < 0.001). Instrumentation failure was statistically linked to the occurrence of L5-S1 pseudarthrosis (p < 0.001). On multivariate analysis, no risk factors were found.

Conclusions: L5-S1 isthmic spondylolisthesis and high PI seem to be risk factors for instrumentation failure in case of stand-alone L5-S1 ALIF, findings that support the necessity of adding percutaneous posterior pedicle screw instrumentation in these cases.

Keywords: ALIF; ALIF = anterior lumbar interbody fusion; AP = anteroposterior; BMP = bone morphogenic protein; C7/SFD = C7 plumb line/sacro-femoral distance ratio; DDD = degenerative disc disease; LL = lumbar lordosis; PI = pelvic incidence; PT = pelvic tilt; SS = sacral slope; SSA = spinosacral angle; degenerative disc disease; isthmic spondylolisthesis; lumbar; mechanical failure; pseudarthrosis; rhBMP-2 = recombinant human bone morphogenetic protein 2.