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Lordosis Recreation in Transforaminal and Posterior Lumbar Interbody Fusion

A Cadaveric Study of the Influence of Surgical Bone Resection and Cage Angle

Robertson, Peter A., MD, FRACS; Armstrong, William A., BS; Woods, Daniel L., BS; Rawlinson, Jeremy J., PhD

doi: 10.1097/BRS.0000000000002705

Study Design. Controlled cadaveric study of surgical technique in transforaminal and posterior lumbar interbody fusion (TLIF and PLIF)

Objective. To evaluate the contribution of surgical techniques and cage variables in lordosis recreation in posterior interbody fusion (TLIF/PLIF).

Summary of Background Data. The major contributors to lumbar lordosis are the lordotic lower lumbar discs. The pathologies requiring treatment with segmental fusion are frequently hypolordotic or kyphotic. Current posterior based interbody techniques have a poor track record for recreating lordosis, although recreation of lordosis with optimum anatomical alignment is associated with better outcomes and reduced adjacent segment change needing revision. It is unclear whether surgical techniques or cage parameters contribute significantly to lordosis recreation.

Methods. Eight instrumented cadaveric motion segments were evaluated with pre and post experimental radiological assessment of lordosis. Each motion segment was instrumented with pedicle screw fixation to allow segmental stabilization. The surgical procedures were unilateral TLIF with an 18° lordotic and 27 mm length cage, unilateral TLIF (18°, 27 mm) with bilateral facetectomy, unilateral TLIF (18°, 27 mm) with posterior column osteotomy (PCO), PLIF with bilateral cages (18°, 22 mm), and PLIF with bilateral cages (24°, 22 mm). Cage insertion used and “insert and rotate” technique.

Results. Pooled results demonstrated a mean increase in lordosis of 2.2° with each procedural step (lordosis increase was serially 1.8°, 3.5°, 1.6°, 2.5°, and 1.6° through the procedures). TLIF and PLIF with PCO increased lordosis significantly compared with unilateral TLIF and TLIF with bilateral facetectomy. The major contributors to lordosis recreation were PCO, and PLIF with paired shorter cages rather than TLIF.

Conclusion. This study demonstrates that the surgical approach to posterior interbody surgery influences lordosis gain and PCO optimizes lordosis gain in TLIF. The bilateral cages used in PLIF are shorter and associated with further gain in lordosis. This information has the potential to aid surgical planning when attempting to recreate lordosis to optimize outcomes.

Level of Evidence: N/A

The Orthopaedic Clinic, Mercy Specialist Centre, Auckland, New Zealand

Medtronic Spine, Memphis, Tennessee.

Address correspondence and reprint requests to Peter A. Robertson, MD, FRACS, The Orthopaedic Clinic, Mercy Specialist Centre, 100 Mountain Road, Epsom 1023, Auckland, New Zealand; E-mail:

Received 2 November, 2017

Revised 10 April, 2018

Accepted 17 April, 2018

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, stocks, employment.

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