Lecture
Comparison of effects of four interbody fusion approaches on the fused and adjacent segments under vibration

https://doi.org/10.1016/j.clinbiomech.2020.105023Get rights and content

Highlights

  • Anteriorlumbar interbody fusion provides more stability for adjacent segments under vibration.

  • The risk of complications in direct lateral lumbar interbody fusion may be the lowest.

  • Direct lateral lumbar interbody fusion may generate more stable and suitable growth environment.

Abstract

Background

Which lumbar fusion approaches having fewer impacts on the lumbar spine, reducing the risk of complications and the most conducive to bone fusion under whole-body vibration is urgent to know.

Objectives

This study researched the best approach under vibration by comparing the effects of four different approaches on the spine, especially regarding some significant indexes related to complications and outcomes.

Methods

The L1-L5 finite element model was modified to simulate anterior, posterior, trans-foraminal and direct lateral lumbar interbody fusion approaches with bilateral pedicle screw fixation at L4-L5 level.

Findings

Anterior lumbar interbody fusion decreased the corresponding vibration amplitude of the dynamic response at adjacent segments compared with the other three approaches. Direct lateral lumbar interbody fusion decreased the maximum stress in the cage, the endplates at the fused level, and the maximum compressive stress at the interface between the cage and endplates. The maximum disc height and segmental lordosis of Direct lateral lumbar interbody fusion model were the highest among these fusion approaches.

Interpretation

Anterior lumbar interbody fusion may provide a more stable environment for the adjacent segments under vibration. Direct lateral lumbar interbody fusion may reduce the risk of subsidence, cage failure, and adjacent segment disease. Direct lateral lumbar interbody fusion may provide a more stable and suitable environment for vertebral cell growth and lead to better fusion outcomes. The findings may help us understand the effect of various fusion approaches on lumbar and provide some references for choosing a fusion approach.

Introduction

Lumbar interbody fusion has been indicated in the management of the degenerative lumbar diseases such as disc degeneration, degenerative spinal stenosis, and spondylolysis for many years (Lo et al., 2011; Min et al., 2007).To restore the stability of the motion lumbar segments and relieve severe lower back pain, many lumbar interbody fusion approaches have been created (Klara et al., 2003; Udby and Bech-Azeddine, 2015). Anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), trans-foraminal lumbar interbody fusion (TLIF) and direct lateral lumbar interbody fusion (DLIF) are four of commonly used approaches for lumbar vertebral fusion with screw-rod fixation (Tang, 2015; Tatsumi et al., 2015; Voor et al., 1998). Each surgery approach has its strengths and weaknesses. The goal of all fusion approaches is to promote bone fusion while reducing complications. Therefore, there have been some valuable results among several approaches. Sim et al. (2010) compared the PLIF and TLIF using the human L2–S2 cadaveric spine specimens and reported that regarding immediate stability, PLIF was better than TLIF, especially in lateral bending. A meta-analysis by Teng et al. (2017) showed that each approach has similar fusion and complication rates among ALIF, PLIF, DLIF, and TLIF. Lee et al., 2017a, Lee et al., 2017b compared the radiological and clinical outcomes about ALIF, PLIF, and DLIF, and found that the 3 different approaches can produce good outcomes, but DLIF was more beneficial to prevent the development of adjacent segment disease. Similarly, there are a lot of numerical results from the finite element model simulating lumbar interbody fusion approaches. Tang (2015) compared the adjacent segment degeneration between the normal, healthy finite element (FE) model of L3–5 adopted TLIF and PLIF and found the influence of PLIF on adjacent segments was greater than TLIF. Finite element analysis by Xu et al. (2013) demonstrated that the biomechanical difference between PLIF and TLIF that TLIF can provide better biomechanical stability and reduce the stress at the interface between cage and endplates. Although many scholars have provided valuable experimental and numerical results to help us understand the effects of lumbar interbody fusion approaches on the biomechanical properties of the lumbar spine, and fusion outcomes and complications (Lee et al., 2017a, Lee et al., 2017b; Sim et al., 2010), most of the studies were carried out under the static load without taking into account the condition of the whole-body vibration.

The whole-body vibration(WBV) is typically present in vehicles, known as one of the serious risk factors leading to spinal disorders (Wade et al., 2016). Whether clinical, experimental results or many studies have shown that WBV led to low back pain (Bovenzi et al., 2017), intervertebral disc injuries (Griffin and Erdreich, 1990; Thalheimer, 1996), sciatic pain (Burström et al., 2015), spinal disorders (Bovenzi et al., 2015) and other lumbar diseases. A meta-analysis by Bovenzi and Hulshof (1998) reported that exposure to WBV was associated with degenerative changes in the spine and intervertebral disc disorders. To investigate the specific results of WBV on spinal injury, many scholars have developed detailed FE models. Goel (1994) developed a nonlinear, three-dimensional FE model of the ligamentous L4-S1 segment to compare the effects of the static loads and vibration loads on the lumbar. They found that vibrations loads produced significant increases in stresses and intradiscal pressure (IDP) of the intervertebral disc, as compared to the static loads. In daily life, whole-body vibrations such as driving a car or taking a bus are very common but inevitable. Because of the instruments and the lack of lumbar spine stability, patients undergoing lumbar fusion surgery are more vulnerable when exposed to WBV. Therefore, the effect of WBV on the patients undergoing lumbar fusion surgery has deserved more attention. An in vivo study by Rohlmann et al. (2010) measured the effect of WBV causing by public transportation on the patient undergoing spinal surgery and found that driving a car or using public transportation systems led to lower implant loads than walking, and can, therefore, be allowed already shortly after surgery. Xu et al. (2016) investigated the effect of WBV on post-surgical of scoliosis subjects by FE studies and indicated that fusion surgery made the resonance frequency higher in the post-surgery scoliosis subject than that for healthy subjects. The purpose of this study was to find which lumbar fusion approaches reduces the risk of complications and is most conducive to bone fusion under whole-body by comparing the effects of ALIF, PLIF, TLIF and, DLIF on adjacent segments and fusion segment under WBV, especially regarding fusion outcomes (vertebral growth) and complications such as adjacent segment disease (ASD) and subsidence.

Section snippets

FE modeling and materials

A previously validated three-dimensional nonlinear FE model of an intact L1-L5 lumbar spine was used in this study (Fan and Guo, 2017; Guo and Yin, 2019). The model mainly includes vertebral body, intervertebral disc, endplate and various ligaments such as anterior longitudinal, posterior longitudinal, capsular, intertransverse, interspinous, supraspinous and flavum ligaments, as shown in Fig. 1. The six-layer annulus fibrosus is present in the annulus ground substance, and the elastic modulus

Validation of the FE model

In this paper, based on the existing in vitro cadaveric experiments and numerical analysis, the L1-L5 spine finite element model was verified. The present model results were compared with experimental data and numerical results (Dreischarf et al., 2014; Renner et al., 2007), including pure moments, pure follower loads, and their combined loads, and are in good agreement with published results. We believe that the developed model is a good representation of the human lumbar spine and can be used

Discussion

Comparative studies of different interbody fusion approaches have been widely concerned, but most of the studies were only under the static load. Comparative studies on the dynamic characteristics of the lumbar spine with different fusion methods (ALIF,PLIF,TLIF, and DLIF) under WBV are rare. Therefore, the present study researched that which lumbar fusion approaches have fewer impacts on the lumbar spine, cause fewer complications and are the most conducive to bone fusion under whole-body

Conclusions

In the present study, we compared the effects of 4 different lumbar interbody fusion approaches (ALIF, PLIF, TLIF, and DLIF) on the fusion segment and adjacent segments under WBV, especially regarding some considerable indexes related to complications and fusion outcomes. The results showed that ALIF may provide a more stable environment for adjacent segments under WBV and have the best anti-vibration capability among four different approaches. DLIF may reduce the risks of subsidence and cage

Acknowledgement

This work was supported by the National Natural Science Foundation of China (51875096, 51275082).

Declaration of Competing Interest

No conflict of interest in this study.

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