Open posterior lumbar interbody fusion should be avoided in the management of lumbar degenerative disc disease (LDDD), concludes a recently published systematic review. The authors, Kuan-Yu Chi and colleagues from Taipei Medical University Hospital, Taipei, Taiwan, write that open posterior lumbar interbody fusion yields a “significantly higher overall adverse event rate”.
On the other hand, the authors specify that transforaminal lumbar interbody fusion confers the safest profile in terms of neural, spinal and vascular events. “Nevertheless,” they note, “shared decision making is still mandatory when choosing the proper lumbar interbody fusion procedure for patients with LDDD in clinical practice.”
In their paper, published in the Global Spine Journal, Chi and colleagues acknowledge that LDDD remains an important issue in an aging population. They write that lumbar interbody fusion is a feasible management approach in cases resistant to conservative therapy, and various techniques currently available to perform the procedure include posterior lumbar interbody fusion, as well as transforaminal and anterior approaches.
However, the team point to the fact that the comparative safety profile of these procedures “remains controversial”. Therefore, they sought to evaluate comparative adverse events of the lumbar interbody fusion procedures in a cohort of patients with LDDD.
“We searched five databases for relevant prospective cohort studies and randomised clinical trials. After quality assessments, we extracted neural, spinal, vascular, and wound events for conducting contrast-based network meta-analysis,” they write.
Chi and the team identified 14 studies involving 921 participants with LDDD. The pooled results of the network meta-analysis demonstrated that open posterior lumbar interbody fusion leads to significantly higher overall adverse event rates than does open transforaminal lumbar interbody fusion (transforaminal; risk ratio [RR]=3.43, 95% confidence interval [CI]: 1.21–9.73).
Moreover, they reported that open transforaminal procedures generated the highest surface under the cumulative ranking (SUCRA) in neural (78.7) and spinal (80.8) events. Minimally invasive transforaminal lumbar interbody fusion has the highest SUCRA in vascular events, the authors added, and minimally invasive posterior lumbar interbody fusion has the highest SUCRA in wound events (88.1).
Discussing the key findings, the team in Taipei note that they “came as no surprise”. This is because open posterior lumbar interbody fusion has been reported to “bear many complications”, including nerve root injury, dural tear, and epidural adhesions. According to the authors, these are compatible with the fact that open posterior lumbar interbody fusion also served the highest rate of neurological (including foot-drop, affections of left sympathetic plexus) and spinal events in their further analyses.
Chi et al allude to two primary limitations of their work. They write: “Because our study would like to avoid inherent biases from retrospective studies, we only synthesised 14 studies with 921 cases. This sample size may lead to pooled estimates under power.” Secondary to this, they acknowledge that surgeon experience when carrying out these procedures is “very important”, yet the team did not find enough information regarding experience in the included studies. Thus, they call for future studies on this topic to provide sufficient information about the surgical team.
Despite the key findings of the current study, the authors explain that their previous work found that minimally invasive posterior, and minimally invasive open posterior lumbar interbody fusion “may have better outcomes in terms of pain relief and Oswestry Disability Index”.
Therefore, Chi and colleagues ultimately concluded that decision–making may be an appropriate approach to choose the lumbar interbody fusion procedure for LDDD before surgery. Looking to the future, they write: “Our evidence only focuses on the most common lumbar interbody fusion procedures, and we anticipate further studies will take lateral lumbar interbody fusion, extreme lateral lumbar interbody fusion, and oblique lumbar interbody fusion into account, though these fusion procedures are not popular in clinical practice now. A comprehensive comparison of such procedures will improve decisions in lumbar interbody fusion surgery.”