Stand-Alone Lateral Lumbar Interbody Fusion at L3-L4 with 3D-Printed Porous Titanium Cages: A Safe and Effective Alternative in the Treatment of Degenerative Disc Disease (DDD)

Abstract

Background/Objectives: Stand-alone lateral lumbar interbody fusion (LLIF) remains a debated approach in spinal surgery, with limited published evidence supporting its efficacy without supplemental fixation. This prospective study presents the institutional case series on single-level L3-L4 stand-alone LLIF, using next-generation 3D-printed titanium cages, as treatment for degenerative disc disease (DDD). Methods: A cohort of 49 patients with symptomatic DDD, unresponsive to conservative therapy, underwent stand-alone LLIF at L3-L4 (neither posterior pedicle screws nor lateral plating). Clinical outcomes (VAS and ODI) and radiological parameters (disc height, segmental/lumbar lordosis) were collected preoperatively and at 1, 6, and 12 months. Repeated-measures ANOVA with Bonferroni correction was adopted for statistical analysis. Results: Significant improvements were observed in pain and disability scores at all time points, with the mean VAS score decreasing from 6.53 to 0.29, and ODI from 27.6% to 3.84% at one year (p < 0.001). Radiographic analysis confirmed durable increases in disc height and segmental lordosis. Solid fusion was achieved in 97.9% of cases. No patient required posterior revision; transient neurological symptoms were mild and self-limiting. Conclusions: This study demonstrates that stand-alone LLIF at L3-L4 is safe and effective in achieving stable fusion and clinical-radiological improvement. These results challenge the necessity of supplemental fixation and support the broader adoption of a less invasive fusion paradigm.

Keywords: LLIF; degenerative disc disease; fusion; intervertebral disc; low back pain; minimally invasive spine surgery; spine.

Figure 1

Changes in Visual Analogue Scale (VAS-back) and Oswestry Disability Index (ODI) scores across the follow-up period. Both clinical parameters show a marked and statistically significant improvement after surgery. The VAS-back score decreased from a baseline of 6.53 to 0.29 at 12 months, while ODI improved from 27.6% to 3.84%, highlighting the effectiveness of stand-alone XLIF in pain relief and functional recovery. Error bars represent standard deviation.

Figure 2

Case presentation. This is the case of a 66-year-old gentleman, suffering from Pfirrman grade IV degenerative disc disease with Modic change at L3-L4 (A), significantly reduced disc height and segmental lordosis (B,C), and 3 mm lateral listhesis of L3 on L4 on the convexity side. The postoperative CT scan (D) and X-rays (E,F) show the implanted 3D printed porous titanium cage correctly positioned at L3-L4, restoring the disc height and the segmental lordosis without subsidence in the inferior endplate. In the one-year dynamic x-rays (G,H), there is no evidence of residual segmental movement or subsidence, while the segmental alignment and disc height are maintained.