Posterior Lumbar Interbody Fusion with Cage and Local Bone Graft in Spondylolisthesis - Unilateral-caged versus Bilateral-caged -

Dong Ki Ahn; Song Lee; Dea Jung Choi; Kwan Soo Kim; Tae Woo Kim

doi:10.4184/jkss.2008.15.2.73

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Ahn, Lee, Choi, Kim, and Kim: Posterior Lumbar Interbody Fusion with Cage and Local Bone Graft in Spondylolisthesis - Unilateral-caged versus Bilateral-caged -

Original Article

Journal of Korean Spine Surg 2008;15(2):73-80.

Published online: 12 February 2008

DOI: https://doi.org/10.4184/jkss.2008.15.2.73

Posterior Lumbar Interbody Fusion with Cage and Local Bone Graft in Spondylolisthesis - Unilateral-caged versus Bilateral-caged -

Dong Ki Ahn, M.D., Song Lee, M.D., Dea Jung Choi, M.D.^∗,, Kwan Soo Kim, M.D., Tae Woo Kim, M.D

Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea

Address reprint requests to Dae Jung Choi, M.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital 40-12 Chungryangri-dong, Dongdaemoon-gu, Seoul Tel: 82-2-966-1616, Fax: 82-2-968-2394, E-mail: niceosu@freechal.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

Retrospective, controlled study

Objective

To compare one and two-caged posterior lumbar interbody fusion (PLIF) with local bone grafting for spondylolisthesis.

Summary of Literature Review

Even though there are many reports on PLIF using cages and local bone grafting, Studies comparing one and two-caged PLIFs are rare.

Materials and Methods

Sixty-three patients who underwent pedicle screw fixated PLIF using cages and local bone grafts were followed for more than 1 year. Twenty-five patients had one cage (group I), and 38 patients had two cages (group II). Sampling error, disc height, sagittal Cobb angle, coronal Cobb angle, fusion rate, Oswestry disability index (ODI), operation time, blood loss, and neurologic complications were assessed.

Results

There was no sampling error between the two groups, except with regard to diagnosis: degenerative spondylolisthesis, 15 cases in group I and 9 cases in group II; spondylolytic spondylolisthesis, 10 cases in group I and 29 cases in group II (p=0.004). Fusion rates were 87.5% and 88.2% for groups I and II, respectively (p=1.000). More disc height loss occurred in group I (0.6 mm) than in group II (0.0 mm) (p=0.041). Over-3mm-disc height-losses were noted more frequently in group I (20%) than in group II (2.6%) (p=0.022). ODI improved from 28.1 to 12.3 (72.1% improvement) in group I and from 29.2 to 12.7 (79.3% improvement) in group II. There were no significant differences in operation time, amount of blood loss, or neurologic complications between the two groups.

Conclusion

Unilateral one-caged PLIF with local bone grafting and posterior instrumentation was no different from bilateral two-caged PLIF with regard to fusion rates or radiologic or clinical results. The statistically significant differences in disc height seemed to be clinically insignificant. Disc height loss of greater than 3 mm was much more common in group I, with one-caged PLIF.

Keywords: Spondylolisthesis, Posterior lumbar interbody fusion, Cage, Local bone

REFERENCES

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Fig. 1.

Complete fusin, with solid bony mass around a cage at anteroposterior and lateral view

Fig. 2.

Probable fusion, with solid bony mass in a cage with small amount of resorption at lateral view.

Fig. 3.

Nonunion, resorption with invisible bony mass more than 50%

Fig. 4.

Undecipherable, with insufficient radiologic information, masked by iliac or sacral bone.

Table 1.

Radiologic classification

Classification	Discrimination
Fusion, complete	Visible bony mass with trabeculation through vertebral body in anteroposterior and lateral view
Fusion, probable	Visible bony mass with trabeculation only in anteroposterior or lateral view with or without small amount of resorption of graft mass
Nonunion	Resorbed bone mass more than 50%
Undecipherable	Disable to interpretation because of insufficient radiologic information

Table 2.

Demography of sampling errors

	Group I	Group II	Significance (p value)
No. of Patients	25	38
Age (years)	56.6±7.92	57.3±9.62	0.593
Sex (M/F)	3/22	11/43	0.495^∗
Medical disease
Diabetes	2	14	0.738^∗
Thyroid disease	0	12	0.244^∗
Smoking	1	18	0.058^∗
Follow-up (months)	23.2±11.5	21.3±10.2	0.438^∗
Diagnosis (Spondylolisthesis)			0.004^∗
Spondylolytic	10	29
Degenerative	15	19
Fusion level			0.710^∗
L3-4	11	12
L4-5	15	26
L5-S1	19	10
Operation times (minutes)	197±282	211±362	0.082^∗
Blood loss (ml)	575±215	615±228	0.485^∗
Neurologic complication	10	10	-

^∗ Pearson Chi-Square, others by Mann-Whitney U-test

Table 3.

Radiological and clinical results

	Group I	Group II	Significance (p value)
Decipherable	24	34	0.933^∗
Fusion, complete	16(66.7%)	23(67.6%)
Fusion, probable	15(20.8%)	7(20.6%)
Resorption	13(12.5%)	4(11.8%)
Undecipherable Oswestry disability index	1	4
Preoperative	28.1±4.91	129.2±4.01	0.364^∗
Postoperative	12.3±3.61	112.7±3.81	0.768^∗
Recovery rate (%) Disc height (mm)	72.1	79.3
Preoperative	10.0±2.51	19.1±3.1	0.287^∗
Postoperative	12.6±1.81	12.0±1.4	0.083^∗
Follow-up	11.9±1.61	112.±1.4	0.947^∗
Reduction loss	0.7±1.3	10.0±1.4	0.038^∗
Frequency of disk height loss more than 3 mm Coronal Cobb angle (degree)	5(20.0%)	1(2.6%)	0.022^∗
Preoperative	0.2±2.9	10.8±3.7	0.417^∗
Postoperative	0.4±2.5	10.0±2.6	0.357^∗
Follow-up	0.3±2.8	10.2±2.9	0.734^∗
Reduction loss Frequency of Coronal Cobb angle	0.1±2.3	10.1±1.9	0.280^∗
loss more than 5 degrees Sagittal Cobb angle (degree)	2(8.0%)	1(2.6%)	0.328^∗
Preoperative	10.2±5.01	19.5±7.2	0.746^∗
Postoperative	12.3±3.91	12.9±4.5	0.843^∗
Follow-up	11.9±3.6	12.6±4.6	0.860^∗
Reduction loss	0.4±1.4	10.2±1.4	0.746^∗
Frequency of Sagittal Cobb angle loss more than 5 degrees	5(20.0%)	7(18.4%)	0.876^∗

^∗ Pearson Chi-Square, others by Mann-Whitney U-test

Table 4.

Results of variable graft-assemblies

Graft-assembly	Authors	Fusion rate	Clinical result	Uniqueness
Allograft	Brantigan JW⁸⁾	56%	60%	Graft failure 28%
Local block bone	Csecsei GI⁹⁾	95.7%	87%	Segmental lordosis loss 2 degrees
Iliac chip bone	Ahn DK¹⁰⁾	90%	88.1%	Donor site pain 12%
Local chip bone & local block bone	Kai Y¹¹⁾	92.9%	76%	Collapsed union 16.7%
Local chip bone	Shin BJ¹²⁾	57%	79%	Difficult radiologic decision 17%
1 cage with local bone	Okuyama K¹⁾	100%	86% (Pain)	Union 93.5%
			62% (Work)	Probable union 6.3%
2 cages with local bone	Miura Y²⁾	100%	76.8%	ASD^∗ 2 cases
Hydroxyapatite block	Asazuma T¹³⁾	96.2%	-	Sinking 23.5%
& Iliac bone block				Cracking of HA block 17.6%

^∗ ASD: Adjacent segmental degeneration

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