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Effects on inadvertent endplate fracture following lateral cage placement on range of motion and indirect spine decompression in lumbar spine fusion constructs: A cadaveric study

Brandon G. Santoni, PhD,1 Gerald E. Alexander III, MD,1 Aniruddh Nayak, MS,1 Andres Cabezas, BS,1 German A. Marulanda, MD,1 Ryan Murtagh, MD,3 Antonio E. Castellvi, MD4

1Phillip Spiegel Orthopaedic Research Laboratory, Foundation for Orthopaedic Research & Education, Tampa, FL 2Department of Orthopaedics & Sports Medicine, University of South Florida, Tampa, FL 3University Diagnostic Institute, Tampa, FL 4Center for Spinal Disorders, Florida Orthopaedic Institute, Tampa, FL

Abstract 

Background

The lateral transpsoas approach to interbody fusion is gaining popularity. Existing literature suggests that perioperative vertebra-related complications include endplate breach owing to aggressive enedplate preparation and poor bone quality. The acute effects of cage subsidence on stabilization and indirect decompression at the affected level are unknown. The purpose of this study was to compare the kinematics and radiographic metrics of indirect decompression in lumbar spines instrumented with laterally placed cages in the presence of inadvertent endplate fracture, which was determined radiographically, to specimens instrumented with lateral cages with intact endplates.

Methods

Five levels in 5 specimens sustained endplate fracture during lateral cage implantation followed by supplementary fixation (pedicle screw/rod [PSR]: n = 1; anterolateral plate [ALP]: n = 4), as part of a larger laboratory-based study. Range of motion (ROM) in these specimens was compared with 13 instrumented specimens with intact endplates. All specimens were scanned using computed tomography (CT) in the intact, noninstrumented condition and after 2-level cage placement with internal fixation under a 400-N follower load. Changes in disc height, foraminal area, and canal area were measured and compared between specimens with intact endplates and fractured endplates.

Results

Subsidence in the single PSR specimen and 4 ALP specimens was 6.5mm and 4.3 ± 2.7mm (range: 2.2–8.3mm), respectively. ROM was increased in the PSR and ALP specimens with endplate fracture when compared with instrumented specimens with intact endplates. In 3 ALP specimens with endplate fracture, ROM in some motion planes increased relative to the intact, noninstrumented spine. These increases in ROM were paralleled by increase in cage translations during cyclic loading (up to 3.3mm) and an unpredictable radiographic outcome with increases or decreases in posterior disc height, foraminal area, and canal area when compared with instrumented specimens with intact endplates.

Conclusions

Endplate fracture and cage subsidence noted radiographically intraoperatively or in the early postoperative period may be indicative of biomechanical instability at the affected level concomitant with a lack of neurologic decompression, which may require revision surgery.

keywords: 
Lumbar interbody fusion, Lateral transpsoas approach, Endplate fracture, Indirect decompression, Stability
Volume 7
doi: 
10.1016/j.ijsp.2013.09.001