Advances in research on Cage subsidence following lumbar interbody fusion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Long ,  ZENG Jiancheng , XIE Tianhang , PU Xingxiao , LU Yufei

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

ZENG Jiancheng, Email: tomzeng5@163.com

Keywords：

Lumbar interbody fusion; Cage subsidence; clinical characteristic; risk factor

DOI：

10.7507/1002-1892.202104036

Video：

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Objective To summarize the advances in research on Cage subsidence following lumbar interbody fusion, and provide reference for its prevention.Methods The definition, development, clinical significance, and related risk factors of Cage subsidence following lumbar interbody fusion were throughout reviewed by referring to relevant domestic and doreign literature in recent years.Results At present, there is no consensus on the definition of Cage subsidence, and mostly accepted as the disk height reduction greater than 2 mm. Cage subsidence mainly occurs in the early postoperative stage, which weakens the radiological surgical outcome, and may further damage the effectiveness or even lead to surgical failure. Cage subsidence is closely related to the Cage size and its placement location, intraoperative endplate preparation, morphological matching of disk space to Cage, bone mineral density, body mass index, and so on.Conclusion The appropriate size and shape of the Cage usage, the posterolateral Cage placed, the gentle endplate operation to prevent injury, the active perioperative anti-osteoporosis treatment, and the education of patients to control body weight may help to prevent Cage subsidence and ensure good surgical results.

Citation： ZHAO Long, ZENG Jiancheng, XIE Tianhang, PU Xingxiao, LU Yufei. Advances in research on Cage subsidence following lumbar interbody fusion. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(8): 1063-1067. doi: 10.7507/1002-1892.202104036 Copy

1.	Mobbs RJ, Phan K, Malham G, et al. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg, 2015, 1(1): 2-18.
2.	Rao PJ, Phan K, Giang G, et al. Subsidence following anterior lumbar interbody fusion (ALIF): a prospective study. J Spine Surg, 2017, 3(2): 168-175.
3.	Marchi L, Abdala N, Oliveira L, et al. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine, 2013, 19(1): 110-118.
4.	Malham GM, Parker RM, Blecher CM, et al. Assessment and classification of subsidence after lateral interbody fusion using serial computed tomography. J Neurosurg Spine, 2015, 23(5): 589-597.
5.	Tohmeh AG, Khorsand D, Watson B, et al. Radiographical and clinical evaluation of extreme lateral interbody fusion: effects of cage size and instrumentation type with a minimum of 1-year follow-up. Spine (Phila Pa 1976), 2014, 39(26): E1582-1591.
6.	Marino JF. Subsidence of metal interbody cage after posterior lumbar interbody fusion with pedicle screw fixation. Orthopedics, 2010, 33(4): 226-227.
7.	Noordhoek I, Koning MT, Jacobs WCH, et al. Incidence and clinical relevance of cage subsidence in anterior cervical discectomy and fusion: a systematic review. Acta Neurochir (Wien), 2018, 160(4): 873-880.
8.	Yao YC, Chou PH, Lin HH, et al. Risk factors of cage subsidence in patients received minimally invasive transforaminal lumbar interbody fusion. Spine (Phila Pa 1976), 2020, 45(19): E1279-E1285.
9.	Choi JY, Sung KH. Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages. Eur Spine J, 2006, 15(1): 16-22.
10.	Satake K, Kanemura T, Nakashima H, et al. Cage subsidence in lateral interbody fusion with transpsoas approach: intraoperative endplate injury or late-onset settling. Spine Surg Relat Res, 2017, 1(4): 203-210.
11.	Kim MC, Chung HT, Cho JL, et al. Subsidence of polyetheretherketone cage after minimally invasive transforaminal lumbar interbody fusion. J Spinal Disord Tech, 2013, 26(2): 87-92.
12.	Kumar A, Kozak JA, Doherty BJ, et al. Interspace distraction and graft subsidence after anterior lumbar fusion with femoral strut allograft. Spine (Phila Pa 1976), 1993, 18(16): 2393-2400.
13.	Cheung KM, Zhang YG, Lu DS, et al. Reduction of disc space distraction after anterior lumbar interbody fusion with autologous iliac crest graft. Spine (Phila Pa 1976), 2003, 28(13): 1385-1389.
14.	Hakało J, Pezowicz C, Wroński J, et al. The process of subsidence after cervical stabilizations by cage alone, cage with plate and plate-cage. A biomechanical comparative study. Neurol Neurochir Pol, 2007, 41(5): 411-416.
15.	Palepu V, Helgeson M, Molyneaux-Francis M, et al. The effects of bone microstructure on subsidence risk foR ALIF, LLIF, PLIF, and TLIF spine cages. J Biomech Eng, 2018. doi: 10.1115/1.4042181.
16.	Lee YS, Kim YB, Park SW. Risk factors for postoperative subsidence of single-level anterior cervical discectomy and fusion: the significance of the preoperative cervical alignment. Spine (Phila Pa 1976), 2014, 39(16): 1280-1287.
17.	Cho JH, Hwang CJ, Kim H, et al. Effect of osteoporosis on the clinical and radiological outcomes following one-level posterior lumbar interbody fusion. J Orthop Sci, 2018, 23(6): 870-877.
18.	Oh KW, Lee JH, Lee JH, et al. The correlation between cage subsidence, bone mineral density, and clinical results in posterior lumbar interbody fusion. Clin Spine Surg, 2017, 30(6): E683-E689.
19.	Lewandrowski KU, Ransom NA, Yeung A. Subsidence induced recurrent radiculopathy after staged two-level standalone endoscopic lumbar interbody fusion with a threaded cylindrical cage: a case report. J Spine Surg, 2020, 6(Suppl 1): S286-S293.
20.	Macki M, Anand SK, Surapaneni A, et al. Subsidence rates after lateral lumbar interbody fusion: A systematic review. World Neurosurg, 2019, 122: 599-606.
21.	Hou Y, Luo Z. A study on the structural properties of the lumbar endplate: histological structure, the effect of bone density, and spinal level. Spine (Phila Pa 1976), 2009, 34(12): E427-433.
22.	Oxland TR, Grant JP, Dvorak MF, et al. Effects of endplate removal on the structural properties of the lower lumbar vertebral bodies. Spine (Phila Pa 1976), 2003, 28(8): 771-777.
23.	Lowe TG, Hashim S, Wilson LA, et al. A biomechanical study of regional endplate strength and cage morphology as it relates to structural interbody support. Spine (Phila Pa 1976), 2004, 29(21): 2389-2394.
24.	Park MK, Kim KT, Bang WS, et al. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J, 2019, 19(3): 437-447.
25.	Zhang X, Wu H, Chen Y, et al. Importance of the epiphyseal ring in OLIF stand-alone surgery: a biomechanical study on cadaveric spines. Eur Spine J, 2021, 30(1): 79-87.
26.	Truumees E, Demetropoulos CK, Yang KH, et al. Effects of disc height and distractive forces on graft compression in an anterior cervical discectomy model. Spine (Phila Pa 1976), 2002, 27(22): 2441-2445.
27.	Kaliya-Perumal AK, Soh TLT, Tan M, et al. Factors influencing early disc height loss following lateral lumbar interbody fusion. Asian Spine J, 2020, 14(5): 601-607.
28.	Pisano AJ, Fredericks DR, Steelman T, et al. Lumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence. Neurosurg Focus, 2020, 49(2): E9. doi: 10.3171/2020.4.FOCUS20286.
29.	Hou Y, Yuan W. Influences of disc degeneration and bone mineral density on the structural properties of lumbar end plates. Spine J, 2012, 12(3): 249-256.
30.	Tempel ZJ, Gandhoke GS, Okonkwo DO, et al. Impaired bone mineral density as a predictor of graft subsidence following minimally invasive transpsoas lateral lumbar interbody fusion. Eur Spine J, 2015, 24 Suppl 3: 414-419.
31.	Buerba RA, Sharma A, Ziino C, et al. Bisphosphonate and teriparatide use in thoracolumbar spinal fusion: A systematic review and meta-analysis of comparative studies. Spine (Phila Pa 1976), 2018, 43(17): E1014-E1023.
32.	Phan K, Rogers P, Rao PJ, et al. Influence of obesity on complications, clinical outcome, and subsidence after anterior lumbar interbody fusion (ALIF): Prospective observational study. World Neurosurg, 2017, 107: 334-341.
33.	Behrbalk E, Uri O, Parks RM, et al. Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using PEEK cage with recombinant human bone morphogenetic protein-2. Eur Spine J, 2013, 22(12): 2869-2875.

1. Mobbs RJ, Phan K, Malham G, et al. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg, 2015, 1(1): 2-18.
2. Rao PJ, Phan K, Giang G, et al. Subsidence following anterior lumbar interbody fusion (ALIF): a prospective study. J Spine Surg, 2017, 3(2): 168-175.
3. Marchi L, Abdala N, Oliveira L, et al. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine, 2013, 19(1): 110-118.
4. Malham GM, Parker RM, Blecher CM, et al. Assessment and classification of subsidence after lateral interbody fusion using serial computed tomography. J Neurosurg Spine, 2015, 23(5): 589-597.
5. Tohmeh AG, Khorsand D, Watson B, et al. Radiographical and clinical evaluation of extreme lateral interbody fusion: effects of cage size and instrumentation type with a minimum of 1-year follow-up. Spine (Phila Pa 1976), 2014, 39(26): E1582-1591.
6. Marino JF. Subsidence of metal interbody cage after posterior lumbar interbody fusion with pedicle screw fixation. Orthopedics, 2010, 33(4): 226-227.
7. Noordhoek I, Koning MT, Jacobs WCH, et al. Incidence and clinical relevance of cage subsidence in anterior cervical discectomy and fusion: a systematic review. Acta Neurochir (Wien), 2018, 160(4): 873-880.
8. Yao YC, Chou PH, Lin HH, et al. Risk factors of cage subsidence in patients received minimally invasive transforaminal lumbar interbody fusion. Spine (Phila Pa 1976), 2020, 45(19): E1279-E1285.
9. Choi JY, Sung KH. Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages. Eur Spine J, 2006, 15(1): 16-22.
10. Satake K, Kanemura T, Nakashima H, et al. Cage subsidence in lateral interbody fusion with transpsoas approach: intraoperative endplate injury or late-onset settling. Spine Surg Relat Res, 2017, 1(4): 203-210.
11. Kim MC, Chung HT, Cho JL, et al. Subsidence of polyetheretherketone cage after minimally invasive transforaminal lumbar interbody fusion. J Spinal Disord Tech, 2013, 26(2): 87-92.
12. Kumar A, Kozak JA, Doherty BJ, et al. Interspace distraction and graft subsidence after anterior lumbar fusion with femoral strut allograft. Spine (Phila Pa 1976), 1993, 18(16): 2393-2400.
13. Cheung KM, Zhang YG, Lu DS, et al. Reduction of disc space distraction after anterior lumbar interbody fusion with autologous iliac crest graft. Spine (Phila Pa 1976), 2003, 28(13): 1385-1389.
14. Hakało J, Pezowicz C, Wroński J, et al. The process of subsidence after cervical stabilizations by cage alone, cage with plate and plate-cage. A biomechanical comparative study. Neurol Neurochir Pol, 2007, 41(5): 411-416.
15. Palepu V, Helgeson M, Molyneaux-Francis M, et al. The effects of bone microstructure on subsidence risk foR ALIF, LLIF, PLIF, and TLIF spine cages. J Biomech Eng, 2018. doi: 10.1115/1.4042181.
16. Lee YS, Kim YB, Park SW. Risk factors for postoperative subsidence of single-level anterior cervical discectomy and fusion: the significance of the preoperative cervical alignment. Spine (Phila Pa 1976), 2014, 39(16): 1280-1287.
17. Cho JH, Hwang CJ, Kim H, et al. Effect of osteoporosis on the clinical and radiological outcomes following one-level posterior lumbar interbody fusion. J Orthop Sci, 2018, 23(6): 870-877.
18. Oh KW, Lee JH, Lee JH, et al. The correlation between cage subsidence, bone mineral density, and clinical results in posterior lumbar interbody fusion. Clin Spine Surg, 2017, 30(6): E683-E689.
19. Lewandrowski KU, Ransom NA, Yeung A. Subsidence induced recurrent radiculopathy after staged two-level standalone endoscopic lumbar interbody fusion with a threaded cylindrical cage: a case report. J Spine Surg, 2020, 6(Suppl 1): S286-S293.
20. Macki M, Anand SK, Surapaneni A, et al. Subsidence rates after lateral lumbar interbody fusion: A systematic review. World Neurosurg, 2019, 122: 599-606.
21. Hou Y, Luo Z. A study on the structural properties of the lumbar endplate: histological structure, the effect of bone density, and spinal level. Spine (Phila Pa 1976), 2009, 34(12): E427-433.
22. Oxland TR, Grant JP, Dvorak MF, et al. Effects of endplate removal on the structural properties of the lower lumbar vertebral bodies. Spine (Phila Pa 1976), 2003, 28(8): 771-777.
23. Lowe TG, Hashim S, Wilson LA, et al. A biomechanical study of regional endplate strength and cage morphology as it relates to structural interbody support. Spine (Phila Pa 1976), 2004, 29(21): 2389-2394.
24. Park MK, Kim KT, Bang WS, et al. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J, 2019, 19(3): 437-447.
25. Zhang X, Wu H, Chen Y, et al. Importance of the epiphyseal ring in OLIF stand-alone surgery: a biomechanical study on cadaveric spines. Eur Spine J, 2021, 30(1): 79-87.
26. Truumees E, Demetropoulos CK, Yang KH, et al. Effects of disc height and distractive forces on graft compression in an anterior cervical discectomy model. Spine (Phila Pa 1976), 2002, 27(22): 2441-2445.
27. Kaliya-Perumal AK, Soh TLT, Tan M, et al. Factors influencing early disc height loss following lateral lumbar interbody fusion. Asian Spine J, 2020, 14(5): 601-607.
28. Pisano AJ, Fredericks DR, Steelman T, et al. Lumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence. Neurosurg Focus, 2020, 49(2): E9. doi: 10.3171/2020.4.FOCUS20286.
29. Hou Y, Yuan W. Influences of disc degeneration and bone mineral density on the structural properties of lumbar end plates. Spine J, 2012, 12(3): 249-256.
30. Tempel ZJ, Gandhoke GS, Okonkwo DO, et al. Impaired bone mineral density as a predictor of graft subsidence following minimally invasive transpsoas lateral lumbar interbody fusion. Eur Spine J, 2015, 24 Suppl 3: 414-419.
31. Buerba RA, Sharma A, Ziino C, et al. Bisphosphonate and teriparatide use in thoracolumbar spinal fusion: A systematic review and meta-analysis of comparative studies. Spine (Phila Pa 1976), 2018, 43(17): E1014-E1023.
32. Phan K, Rogers P, Rao PJ, et al. Influence of obesity on complications, clinical outcome, and subsidence after anterior lumbar interbody fusion (ALIF): Prospective observational study. World Neurosurg, 2017, 107: 334-341.
33. Behrbalk E, Uri O, Parks RM, et al. Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using PEEK cage with recombinant human bone morphogenetic protein-2. Eur Spine J, 2013, 22(12): 2869-2875.

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