Abstract
Background
Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height.
Questions/Purposes
We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine.
Methods
Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review.
Results
Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK–titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation.
Conclusions
All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.
Similar content being viewed by others
References
Alimi M, Shin B, Macielak M, et al. Expandable polyaryl-ether-ether-ketone spacers for interbody distraction in the lumbar spine. Global Spine J. 2015;5:169–178.
Alvi MA, Alkhataybeh R, Wahood W, et al. The impact of adding posterior instrumentation to transpsoas lateral fusion: a systematic review and meta-analysis. J Neurosurg Spine. 2018;30:211–221.
Arnold PM, Anderson KK, McGuire RA Jr. The lateral transpsoas approach to the lumbar and thoracic spine: a review. Surg Neurol Int. 2012;3(Suppl 3):S198–S215.
Audat Z, Moutasem O, Yousef K, Mohammad B. Comparison of clinical and radiological results of posterolateral fusion, posterior lumbar interbody fusion and transforaminal lumbar interbody fusion techniques in the treatment of degenerative lumbar spine. Singap Med J. 2012;53:183–187.
Barbagallo GM, Albanese V, Raich AL, Dettori JR, Sherry N, Balsano M. Lumbar lateral interbody fusion (LLIF): comparative effectiveness and safety versus PLIF/TLIF and predictive factors affecting LLIF outcome. Evid Based Spine Care J. 2014;5(1):28–37.
Behrbalk E, Uri O, Parks RM, Musson R, Soh RC, Boszczyk BM. 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;22:2869–2875.
Bocahut N, Audureau E, Poignard A. Incidence and impact of implant subsidence after stand-alone lateral lumbar interbody fusion. Orthop Traumatol Surg Res. 2018;104(3):405–410.
Briggs H, Milligan PR. Chip fusion of the low back following exploration of the spinal canal. J Bone Joint Surg Am. 1944;26(1):125–130.
Chen Y, Wang X, Lu X, et al. Comparison of titanium and polyetheretherketone (PEEK) cages in the surgical treatment of multilevel cervical spondylotic myelopathy: a prospective, randomized, control study with over 7-year follow-up. Eur Spine J. 2013;22:1539–1546.
Chong E, Pelletier MH, Mobbs RJ, Walsh WR. The design evolution of interbody cages in anterior cervical discectomy and fusion: a systematic review. BMC Musculoskelet Disord. 2015;16:99.
Chou YC, Chen DC, Hsieh WA, et al. Efficacy of anterior cervical fusion: comparison of titanium cages, polyetheretherketone (PEEK) cages and autogenous bone grafts. J Clin Neurosci. 2008;15:1240–1245.
Cuzzocrea F, Ivone A, Jannelli E, Fioruzzi A, Ferranti E, Vanelli R, Benazzo F. PEEK versus metal cages in posterior lumbar interbody fusion: a clinical and radiological comparative study. Musculoskelet Surg. 2019 Dec;103(3):237-241. https://doi.org/10.1007/s12306-018-0580-6. Epub 2018 Dec 10.
De Bartolo L, Morelli S, Bader A, Drioli E. The influence of polymeric membrane surface free energy on cell metabolic functions. J Mater Sci Mater Med. 2001;12(10–12):959–963.
Dorward IG, Lenke LG, Bridwell KH, et al. Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis. Spine (Phila Pa 1976). 2013;38:E755–E762.
Eck JC, Hodges S, Humphreys SC. Minimally invasive lumbar spinal fusion. J Am Acad Orthop Surg. 2007;15:321–329.
Fan SW, Hu ZJ, Fang XQ, Zhao FD, Huang Y, Yu HJ. Comparison of paraspinal muscle injury in one-level lumbar posterior inter-body fusion: modified minimally invasive and traditional open approaches. Orthop Surg. 2010;2:194–200.
Faundez AA, Mehbod AA, Wu C, Wu W, Ploumis A, Transfeldt EE. Position of interbody spacer in transforaminal lumbar interbody fusion: effect on 3-dimensional stability and sagittal lumbar contour. J Spinal Disord Tech. 2008;21(3):175–180.
Fujimori T, Le H, Schairer WW, Berven SH, Qamirani E, Hu SS. Does transforaminal lumbar interbody fusion have advantages over posterolateral lumbar fusion for degenerative spondylolisthesis? Global Spine J. 2015;5:102–109.
Gallo J, Holinka M, Moucha CS. Antibacterial surface treatment for orthopaedic implants. Int J Mol Sci. 2014;15(8):13849–13880.
Ge DH, Stekas ND, Varlotta CG, et al. Comparative analysis of two transforaminal lumbar interbody fusion techniques: open TLIF versus Wiltse MIS TLIF. Spine (Phila Pa 1976). 2019;44(9):e555–e560.
Hijji FY, Narain AS, Bohl DD, et al. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017;17:1412–1419.
Hsieh PC, Koski TR, O’Shaughnessy BA, et al. Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance. J Neurosurg Spine. 2007;7:379–386.
Huang KT, Hazzard M, Thomas S, et al. Differences in the outcomes of anterior versus posterior interbody fusion surgery of the lumbar spine: a propensity score–controlled cohort analysis of 10,941 patients. J Clin Neurosci. 2015;22:848–853.
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine. 2001;26:567–571.
Jagannathan J, Sansur CA, Oskouian RJ Jr, Fu KM, Shaffrey CI. Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion. Neurosurgery. 2009;64:955–963; discussion 963–954.
Kakinuma H, Ishii K, Ishihama H, et al. Antibacterial polyetheretherketone implants immobilized with silver ions based on chelate-bonding ability of inositol phosphate: processing, material characterization, cytotoxicity, and antibacterial properties. J Biomed Mater Res A. 2015;103(1):57–64.
Karikari IO, Jain D, Owens TR, et al. Impact of subsidence on clinical outcomes and radiographic fusion rates in anterior cervical discectomy and fusion: a systematic review. J Spinal Disord Tech. 2014;27:1–10.
Keorochana G, Setrkraising K, Woratanarat P, Arirachakaran A, Kongtharvonskul J. Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis. Neurosurg Rev. 2018;41:755–770.
Khechen B, Haws BE, Patel DV, et al. Comparison of postoperative outcomes between primary minimally invasive TLIF and minimally invasive TLIF with revision decompression. Spine (Phila Pa 1976). 2019;44:150–156.
Kim JS, Lee KY, Lee SH, Lee HY. Which lumbar interbody fusion technique is better in terms of level for the treatment of unstable isthmic spondylolisthesis? J Neurosurg Spine. 2010;12:171–177.
Kim MC, Chung HT, Cho JL, Kim DJ, Chung NS. Subsidence of polyetheretherketone cage after minimally invasive transforaminal lumbar interbody fusion. J Spinal Disord Tech. 2013;26(2):87–92.
Kleimeyer JP, Cheng I, Alamin TF, et al. Selective anterior lumbar interbody fusion for low back pain associated with degenerative disc disease versus nonsurgical management. Spine (Phila Pa 1976). 2018;43:1372–1380.
Lazennec JY, Ramare S, Arafati N, et al. Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain. Eur Spine J. 2000;9:47–55.
Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine (Phila Pa 1976). 2012;37:1268–1273.
Lee YS, Park SW, Kim YB. Direct lateral lumbar interbody fusion: clinical and radiological outcomes. J Korean Neurosurg Soc. 2014;55:248–254.
Lestini WF, Fulghum JS, Whitehurst LA. Lumbar spinal fusion: advantages of posterior lumbar interbody fusion. Surg Technol Int. 1994;3:577–590.
Li JX, Phan K, Mobbs R. Oblique lumbar interbody fusion: technical aspects, operative outcomes, and complications. World Neurosurg. 2017;98:113–123.
Liang Y, Shi W, Jiang C, et al. Clinical outcomes and sagittal alignment of single-level unilateral instrumented transforaminal lumbar interbody fusion with a 4 to 5-year follow-up. Eur Spine J. 2015;24(11):2560–2566.
Lin GX, Akbary K, Kotheeranurak V, et al. Clinical and radiologic outcomes of direct versus indirect decompression with lumbar interbody fusion: a matched-pair comparison analysis. World Neurosurg. 2018;119:e898–e909.
Malham GM, Ellis NJ, Parker RM, Seex KA. Clinical outcome and fusion rates after the first 30 extreme lateral interbody fusions. Scientific World Journal . 2012;2012:246989.
Malham GM, Parker RM, Ellis NJ, Blecher CM, Chow FY, Claydon MH. Anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2: a prospective study of complications. J Neurosurg Spine. 2014;21:851–860.
Malham GM, Parker RM, Goss B, Blecher CM. Clinical results and limitations of indirect decompression in spinal stenosis with laterally implanted interbody cages: results from a prospective cohort study. Eur Spine J. 2015;24 Suppl 3:339–345.
Malham GM, Ellis NJ, Parker RM, et al. Maintenance of segmental lordosis and disk height in stand-alone and instrumented extreme lateral interbody fusion (XLIF). Clin Spine Surg. 2017;30:E90–E98.
McAfee PC, DeVine JG, Chaput CD, et al. The indications for interbody fusion cages in the treatment of spondylolisthesis: analysis of 120 cases. Spine (Phila Pa 1976). 2005;30:S60–S65.
McGilvray KC, Easley J, Seim HB, et al. Bony ingrowth potential of 3D-printed porous titanium alloy: a direct comparison of interbody cage materials in an in vivo ovine lumbar fusion model. Spine J. 2018;18:1250–1260.
Mehren C, Mayer HM, Zandanell C, Siepe CJ, Korge A. The oblique anterolateral approach to the lumbar spine provides access to the lumbar spine with few early complications. Clin Orthop Relat Res. 2016;474:2020–2027.
Miscusi M, Ramieri A, Forcato S, et al. Comparison of pure lateral and oblique lateral inter-body fusion for treatment of lumbar degenerative disk disease: a multicentric cohort study. Eur Spine J. 2018;27:222–228.
Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIFJ Spine Surg. 2015;1(1):2–18.
Mobbs RJ, Phan K, Assem Y, Pelletier M, Walsh WR. Combination Ti/PEEK ALIF cage for anterior lumbar interbody fusion: early clinical and radiological results. J Clin Neurosci. 2016;34:94–99.
Mobbs RJ, Phan K, Daly D, Rao PJ, Lennox A. Approach-related complications of anterior lumbar interbody fusion: results of a combined spine and vascular surgical team. Global Spine J. 2016;6:147–154.
Najeeb S, Khurshid Z, Matinlinna JP, Siddiqui F, Nassani MZ, Baroudi K. Nanomodified PEEK dental implants: bioactive composites and surface modification—a review. Int J Dent. 2015;2015:381759.
Nemoto O, Asazuma T, Yato Y, Imabayashi H, Yasuoka H, Fujikawa A. Comparison of fusion rates following transforaminal lumbar interbody fusion using polyetheretherketone cages or titanium cages with transpedicular instrumentation. Eur Spine J. 2014;23:2150–2155.
Niu CC, Liao JC, Chen WJ, Chen LH. Outcomes of interbody fusion cages used in 1 and 2-levels anterior cervical discectomy and fusion: titanium cages versus polyetheretherketone (PEEK) cages. J Spinal Disord Tech. 2010;23:310–316.
Noiset O, Schneider YJ, Marchand-Brynaert J. Fibronectin adsorption or/and covalent grafting on chemically modified PEEK film surfaces. J Biomater Sci Polym Ed. 1999;10:657–677.
Noordhoek I, Koning MT, Jacobs WCH, Vleggeert-Lankamp CLA. Incidence and clinical relevance of cage subsidence in anterior cervical discectomy and fusion: a systematic review. Acta Neurochir. 2018;160:873–880.
Ohtori S, Orita S, Yamauchi K, et al. Mini-open anterior retroperitoneal lumbar interbody fusion: oblique lateral interbody fusion for lumbar spinal degeneration disease. Yonsei Med J. 2015;56:1051–1059.
Olivares-Navarrete R, Gittens RA, Schneider JM, et al. Osteoblasts exhibit a more differentiated phenotype and increased bone morphogenetic protein production on titanium alloy substrates than on poly-ether-ether-ketone. Spine J. 2012;12:265–272.
Olivares-Navarrete R, Hyzy SL, Gittens RAs, et al. Rough titanium alloys regulate osteoblast production of angiogenic factors. Spine J. 2013;13:1563–1570.
Phan K, Mobbs RJ. Oblique lumbar interbody fusion for revision of non-union following prior posterior surgery: a case report. Orthop Surg. 2015;7:364–367.
Phan K, Rao PJ, Scherman DB, Dandie G, Mobbs RJ. Lateral lumbar interbody fusion for sagittal balance correction and spinal deformity. J Clin Neurosci. 2015;22:1714–1721.
Phan K, Thayaparan GK, Mobbs RJ. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion—systematic review and meta-analysis. Br J Neurosurg. 2015;29:705–711.
Rao PJ, Pelletier MH, Walsh WR, Mobbs RJ. Spine interbody implants: material selection and modification, functionalization and bioactivation of surfaces to improve osseointegration. Orthop Surg. 2014;6:81–89.
Rao PJ, Ghent F, Phan K, Lee K, Reddy R, Mobbs RJ. Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis. J Clin Neurosci. 2015;22:1619–1624.
Rao PJ, Maharaj MM, Phan K, Lakshan Abeygunasekara M, Mobbs RJ. Indirect foraminal decompression after anterior lumbar interbody fusion: a prospective radiographic study using a new pedicle-to-pedicle technique. Spine J. 2015;15:817–824.
Rao PJ, Phan K, Giang G, Maharaj MM, Phan S, Mobbs RJ. Subsidence following anterior lumbar interbody fusion (ALIF): a prospective study. J Spine Surg. 2017;3:168–175.
Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine. 2005;2:670–672.
Rickert M, Fleege C, Tarhan T, et al. Transforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot study. Bone Joint J. 2017;99-B(10):1366–1372.
Sakeb N, Ahsan K. Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability. Indian J Orthop 2013;47(3):255–263.
Schimmel JJ, Poeschmann MS, Horsting PP, Schonfeld DH, van Limbeek J, Pavlov PW. PEEK cages in lumbar fusion: mid-term clinical outcome and radiologic fusion. Clin Spine Surg. 2016;29:E252–E258.
Schwab FJ, Smith VA, Biserni M, Gamez L, Farcy JP, Pagala M. Adult scoliosis: a quantitative radiographic and clinical analysis. Spine (Phila Pa 1976). 2002;27:387–392.
Seaman S, Kerezoudis P, Bydon M, Torner JC, Hitchon PW. Titanium vs. polyetheretherketone (PEEK) interbody fusion: meta-analysis and review of the literature. J Clin Neurosci. 2017;44:23–29.
Silvestre C, Mac-Thiong JM, Hilmi R, Roussouly P. Complications and morbidities of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lumbar interbody fusion in 179 patients. Asian Spine J. 2012;6:89–97.
Upadhyayula PS, Curtis EI, Yue JK, Sidhu N, Ciacci JD. Anterior versus transforaminal lumbar interbody fusion: perioperative risk factors and 30-day outcomes. Int J Spine Surg. 2018;12:533–542.
Wuertz-Kozak K, Bleisch D, Nadi N, et al. Sexual and urinary function following anterior lumbar surgery in females. Neurourol Urodyn. 2019;38(2):632–636.
Yee TJ, Joseph JR, Terman SW, Park P. Expandable vs static cages in transforaminal lumbar interbody fusion: radiographic comparison of segmental and lumbar sagittal angles. Neurosurgery. 2017;81:69–74.
Yilmaz E, Iwanaga J, Moisi M, et al. Risks of colon injuries in extreme lateral approaches to the lumbar spine: an anatomical study. Cureus. 2018;10:e2122.
Zhang Q, Yuan Z, Zhou M, Liu H, Xu Y, Ren Y. A comparison of posterior lumbar interbody fusion and transforaminal lumbar interbody fusion: a literature review and meta-analysis. BMC Musculoskelet Disord. 2014;15:367.
Zhang Z, Li H, Fogel GR, Liao Z, Li Y, Liu W. Biomechanical analysis of porous additive manufactured cages for lateral lumbar interbody fusion: a finite element analysis. World Neurosurg. 2018;111:e581–e591.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Ravi Verma, MD, MBA, and Sohrab Virk, MD, MBA, declare that they have no conflicts of interest. Sheeraz Qureshi, MD, MBA, reports receiving consulting fees or royalties from Stryker, K2M, Paradigm Spine, Globus Medical, Medical Device Business Services, and Pacira Pharmaceuticals; owning shares of Avaz Surgical and Vital 5; and receiving royalties from RTI and Zimmer Biomet, outside the submitted work.
Human/Animal Rights
N/A
Informed Consent
N/A
Required Author Forms:
Disclosure forms provided by the authors are available with the online version of this article.
Rights and permissions
About this article
Cite this article
Verma, R., Virk, S. & Qureshi, S. Interbody Fusions in the Lumbar Spine: A Review. HSS Jrnl 16, 162–167 (2020). https://doi.org/10.1007/s11420-019-09737-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11420-019-09737-4