Gómez López, Ricardo Axel¹,²,⁶; Chavira Ramos, Pedro Arnulfo¹,³,⁷; Díaz Bello, Sergio¹,²,⁸; Chávez Lizárraga, Diana¹,⁴,⁹; Cantú Chávez, Emmanuel¹,²,¹⁰; Peña Blesa, Ana Sofía¹,⁵,¹¹; Pérez Contreras, Jesús Alberto¹,²,¹²

Language: English/Spanish [Versión en español]
References: 5
Page: 142-146
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ABSTRACT

Introduction: lumbar fusion procedures carry the risk of developing pseudoarthrosis. Despite their prevalence, few studies have characterized the clinical efficacy of life-saving procedures. Clinical case: a 65-year-old male with lumbar pain since undergoing an L5-S1 TLIF (Transforaminal Lumbar Interbody Fusion) procedure four years ago. With claudication and left-sided radicular pain. X-ray revealed adjacent segment disease and L5-S1 pseudoarthrosis. Conservative treatment was initiated without improvement of symptoms. Reconstruction of segmental lordosis by ALIF (Anterior Lumbar Interbody Fusion) is proposed as a rescue procedure. The patient presented improvement in pain and disability Index and evidence of arthrodesis and improvement in segmental spinopelvic parameters at the 3-month follow-up. Conclusions: using ALIF as a revision surgery for TLIF pseudoarthrosis proved highly effective for arthrodesis, improvement of spinopelvic parameters, and global sagittal alignment.

ABBREVIATIONS:

• ALIF = Anterior Lumbar Interbody Fusion
• PEEK = polyetheretherketone
• TLIF = Transforaminal Lumbar Interbody Fusion

INTRODUCTION

Lumbar fusion is influenced by the surgical technique, including endplate preparation, patient factors, and the choice of bone graft. If fusion is incomplete, there is a risk of developing a painful pseudoarthrosis.¹ Despite its prevalence, few studies have characterized the clinical efficacy of salvage procedures.²

The ALIF (Anterior Lumbar Interbody Fusion) technique is an attractive option for revision lumbar interbody fusion, as it provides broad access for implant removal and graft placement with a larger area to promote fusion,³ decreasing the risk of neurological injury.⁴

The ALIF procedure not only presents radiographic advantages in bone fusion,⁵ but also redistributes the anterior load, grants a larger contact surface increasing the fusion potential, and this technique reduces blood loss, surgical time, and muscle trauma compared to posterior approach techniques.

CASE PRESENTATION

A 65-year-old male presented with refractory lumbar pain and claudication following an L5-S1 transforaminal lumbar interbody fusion (TLIF) performed four years ago. Evidence of adjacent segment disease, grade 1 L4-L5 listhesis, L5-S1 pseudoarthrosis, and a fracture of the left S1 screw was noted. Spinopelvic parameters included pelvic incidence 44.2, pelvic tilt 5.6, sacral slope 38.7, lumbar lordosis 57, and segmental lordosis 45.4 (anteverted Roussouly type 3) (Figure 1).

A magnetic resonance imaging study revealed grade 3 Pfirrmann L4-L5 disc degeneration, grade 4 Pfirrmann L5-S1 disc degeneration, the presence of hydrarthrosis and a 1 mm right facet hypertrophy, circumferential L4-L5 disc protrusion, and L5-S1 intervertebral narrowing with a banana-type interbody implant showing erosion and subsidence into the endplates (Figure 2).

A lumbosacral computed tomography scan identified interbody bone bridging at L5-S1, as well as left facet fusion; however, signs of pseudoarthrosis at the level of the right facet, left L4-L5 facet arthrosis, sclerotic endplates, interbody cage subsidence, and sites of osteolysis were present (Figure 3).

TREATMENT DESCRIPTION

A reconstruction of segmental lordosis using the ALIF technique was proposed.

Osteosynthesis material was removed, and a left L5-S1 facetectomy was performed to allow distraction and preparation of the L5-S1 space. Through an anterior retroperitoneal lumbar approach, the banana-type PEEK (polyetheretherketone) cage was removed; remodeling of the posterior osteophyte and preparation of the endplates were carried out. An ALIF cage plus anterior fixation with two screws was placed. The patient was then repositioned to the prone position; a transforaminal L4-L5 approach was performed for the placement of an expandable cage and the insertion of five percutaneous screws (right L4-S1, left L4-L5). Postoperative radiographic control and measurement of spinopelvic parameters were performed (Figure 4).

DISCUSSION

The goals of lumbar fusion revision surgery include correcting technical errors, placing superior quality graft material, maximizing endplate preparation, and improving the biological and biomechanical environment for fusion. The ALIF technique allows for the removal of the previously placed implant, reducing the risks of nerve root injury associated with a posterior approach and preserving the paravertebral musculature; furthermore, it allows for the release of the anterior longitudinal ligament, which contributes to the placement of an implant with greater height and lordosis.

Achieving a spine with an adequate lordosis distribution index for the specific spine type according to Roussouly, while respecting the sagittal apex and the number of lordotic vertebrae, decreases the risk of proximal failure. Maintaining harmonic parameters between the sacral slope, segmental lordosis, and a pelvic tilt of less than 10 degrees on the radiographic control indicates the absence of compensatory mechanisms by the patient.

CONCLUSIONS

The use of ALIF as a revision surgery for TLIF pseudoarthrosis demonstrated high effectiveness for arthrodesis, as well as improvement in segmental spinopelvic and clinical parameters.

REFERENCES

1. Etminan M, Girardi FP, Khan SN, Cammisa FP Jr. Revision strategies for lumbar pseudarthrosis. Orthop Clin North Am. 2002; 33 (2): 381-392. doi: 10.1016/s0030-5898(02)00005-6.

2. Jacob K, Patel M, Prabhu M, Vanjani N, Pawlowski H, Singh K. 212. ALIF as a salvage procedure for TLIF pseudarthrosis: a clinical outcome study. Spine J. 2022; 22: S112-S113. doi: 10.1016/j.spinee.2022.06.232.

3. Shih CM, Hsu CE, Chen KH, Pan CC, Lee CH. Surgical outcomes of anterior lumbar interbody fusion in revision lumbar interbody fusion surgery. J Orthop Surg Res. 2023; 18 (1): 497. doi: 10.1186/s13018-023-03972-6.

4. Safaee MM, Tenorio A, Haddad AF, Wu B, Hu SS, Tay B et al. Anterior lumbar interbody fusion with cage retrieval for the treatment of pseudarthrosis after transforaminal lumbar interbody fusion: a single-institution case series. Oper Neurosurg. 2021; 20 (2): 164-173. doi: 10.1093/ons/opaa303.

5. Mobbs RJ, Phan K, Thayaparan GK, Rao PJ. Anterior lumbar interbody fusion as a salvage technique for pseudarthrosis following posterior lumbar fusion surgery. Global Spine J. 2016; 6 (1): 14-20. doi: 10.1055/s-0035-1555656.

AFFILIATIONS

¹ Hospital Angeles México. Ciudad de México.

² Neurocirugía y Cirugía de Columna.

³ Traumatología y Ortopedia, Cirugía de Columna.

⁴ Medicina General e Investigación.

⁵ Anestesia y Medicina del Dolor.
ORCID:

⁶ 0009-0005-0758-0911

⁷ 0009-0000-0909-7476

⁸ 0009-0005-2350-8565

⁹ 0009-0009-4931-2041

¹⁰ 0009-0000-6553-6840

¹¹ 0009-0008-0519-3354

¹² 0000-0001-8641-2150

If you wish to consult the supplementary data for this article, please contact editorial.actamedica@saludangeles.mx

CORRESPONDENCE

Dr. Ricardo Axel Gómez López . Correo electrónico: diancha@gmail.com

Received: 2024-11-06. Accepted: 2025-03-13.