RESULTS OF REVISION SURGERY FOR DEGENERATIVE DYSTROPHIC DISEASES OF THE LUMBOSACRAL SPINE Abakirov M.D., Nurmukhametov R.M., Mamyrbaev S.T., Al-Bavarid O.A.
Peoples’ Friendship University of Russia,
Central Clinical Hospital of Russian Academy of Sciences,
City Clinical Hosptal No.17,
Demikhov City Clinical Hospital, Moscow, Russia
Degenerative dystrophic diseases of the lumbosacral spine present the common problem for healthcare in the whole world. According to V.M. Ravindra et al., about 266 million people (3.63 %) acquire this disease each year [1]. Despite of high amount of surgical interventions for treatment of degenerative diseases of the lumbar spine, the requirement for revision surgery has been increasing [2]. The values of satisfactory outcomes of revision surgery for degenerative diseases of the lumbar spine vary from 15 to 89.3 % [3]. The positive outcomes of recurrent surgery for recurrent disk hernia are achieved in 96.8 %, for recurrent stenosis of the spinal canal – in 75 %, for unstable spinal motion segment – in 84.6 % [2].
However, despite of significant advances in surgical management of degenerative diseases of the spine, the outcomes are not satisfactory in all cases [4]. Poor outcomes of surgical interventions for the lumbosacral spine are 10-40 % [5]. For surgical interventions for degenerative diseases of the spine, the incidence of revision surgery is 40-44 % (The International Spine Registry SPINE TANGO, 2008). More than 87 % of revision operations, which were performed within the first 3 years after primary surgery, were associated with failed back surgery syndrome (FBSS) [6]. The incidence of recurrent surgery after primary discectomy is 5-18 % [7]. According to Seung-PyoSuhetal, 9-45 % of patients receive revision surgery due to recurrent pain after primary surgical interventions [8]. According to Kim C.H. et al., the values of recurrent interventions depending on a surgical technique in their retrospective cohort study were 5.4 % in 3 months, 7.4 % – after one year, 9 % – after 2 years, 10.5 % – after 3 years, 12.1 % – after 4 years, 13.4 % – after 5 years. The rates of recurrent surgery after laminectomy were 18.6 %, after nucleolysis – 14.7 %, after opened discectomy – 13.8 %, after endoscopic discectomy – 12.4 %, after spondylodesis – 11.8 % [7].
Recurrent surgical interventions are carried out due to postsurgical complications or technical errors, as well as owing to progressing degenerative changes such as recurrent stenosis, unstable spinal motion segment, adjacent segment syndrome or in combination of all factors [9]. Back pain due to unstable spinal segment varies from 4 to 30 % [10]. According to J.C. tang et al., after subtotal laminectomy, the instability of the spinal motion segment was more often after bilateral partial hemilaminectomy or unilateral laminectomy (45.5 %, 37.5 % and 16.7 %, correspondingly) [11]. The subanalysis of 8-year data from Spine Patient Outcome Research Trial (SPORT) showed that recurrent surgery for spinal canal stenosis was 8 %, including 52 % for recurrent stenosis; 42 % of procedures were conducted within 2 years, 70 % – within 4 years, 84 % –within 6 years [12]. The values of revision procedures for spinal canal stenosis after decompression with spondylodesis were 9.7 %, and 7.2 % after decompression in one year; after 2 years – 14.6 % and 12.5 %, correspondingly [13].
Currently, lumbar spine spondylodesis is conducted for various spine diseases including degenerative diseases. The satisfactory results vary from16 to 95 %. However, some poor outcomes are registered, including pseudoarthrosis (6-36 %) [14]. Pseudoarthrosis is one of the main causes of pain syndrome, and is the most common indication for revision surgery [15]. According to some authors, the rates of pseudoarthrosis varied from 3 to 56 % after lumbar fusion [16-17]. Recurrent intervertebral disk hernia is the common problem for spinal surgery, with incidence of 2-25 % [18-19]. Adjacent segment disease is a degenerative process developing in mobile segments above or beneath the operated segment, with incidence of 2-9 %. The incidence of the X-ray sign of adjacent segment disease varies from 5.2 to 100 % after lumbar spine surgery, the values of symptomatic syndrome of the adjacent segment – from 2 to 30 %; 6.3-77 % of case – above the operated segment, 13 % – beneath the operated level [20].
Objective – to conduct the comparative analysis of results of revision surgery for degenerative dystrophic diseases of the lumbosacral spine with use of transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF).
Figure 1
The scheme (axial view) of surgical approach with use of ALIF and TLIF
MATERIALS AND METHODS
The study included 50 patients with degenerative dystrophic diseases of the lumbosacral spine treated with revision surgery with ALIF and TLIF in 2017-2019. The patients were distributed into two groups according to a surgical technique. The group 1 consisted of 26 patients, age of 31-84 (Ì ± SD = 59.8 : 14.0), operated with TLIF. There were 12 men (46.2 %) and 14 women (53.8 %). Pain was estimated with VAS (Ì ± SD = 7.8 : 0.8 points). Oswestry index (Ì ± SD = 56.2 : 10.2). The group 2 consisted of 24 patients, age of 23-67, (Ì ± SD = 46.9 : 12.3), operated with ALIF. The ratio men-women was 16 (66.7 %) : 8 (33.3 %) in this group. Pain according to VAS (Ì ± SD = 50.4 : 11.5 points). Oswestry index (Ì ± SD = 56.2 : 10.2 %) (table 1).
Table 1
Presurgical demographic and clinical characteristics of patients according to surgery technique
|
Features |
Number of patients (%) |
p* |
|
|---|---|---|---|
|
|
Group 1 (n = 26) |
Group 2 (n = 24) |
|
|
Gender: |
|
|
p > 0.05 |
|
male |
12 (46.2%) |
16 (66,7%) |
|
|
female |
14 (53.8%) |
8 (33,3%) |
|
|
Age, Ì ± SD, range (years) |
59.8 ± 14.0 31.0–84.0 |
46.9 ± 12.3 23.0-67.0 |
p < 0.01 |
|
ODI before surgery, Ì ± SD; |
56.2 ± 10.2 |
50.4 ± 11.5 |
p = 0.1 |
|
VAS before surgery, Ì ± SD; |
7.8 ± 0.8 |
7.3 ± 1.2 |
p > 0.05 |
Note: group 1 – decompressive stabilizing intervention with TLIF; group 2 – anterior decompression with ALIF in combination with TPF; * – level of significance of differences according to Mann-Whitney’s U-test.
The inclusion criteria were any revision surgery for recurrent stenosis or disk hernia, abnormalities in the adjacent level, pseudoarthrosis, progressing degenerative pathology or development of consequences relating to implanted devices or fixing system.
The exclusion criteria were surgical management of traumatic pathology, primary infectious lesion of the spine of their consequences; early postsurgical revision surgery for abnormal surgical wound, including hematoma or cerebrospinal fluid leakage, inadequate decompression or discectomy, inadequate implantation of interbody implants or supporting elements of fixing system.
Clinical and neurological examination: chronic pain in the back (VAS > 4 and/or ODI > 30 % within at least 3 last months); neurogenic intermittent claudication; root pain syndrome or disordered sensitivity (all variants) in absence of effect of conservative therapy; motion disorders (with muscular strength of 3 points and less).
The complex of presurgical radiologic diagnosis included plain and functional X-ray imaging, multi-spiral computer tomography(MSCT),magnetic resonance imaging (MRI). Survey spondilography was oriented to identification of common signs of degenerative lesion of the spine: subchondral sclerosis, decreasing height of the intervertebral disk, changes in shape of vetrebrae and facet joints, and spine deformation. X-ray imaging with functional tests (in end positions of extension and flexion) was carried out for estimating the position of metal elements, and for assessing the instability of the construct or adjacent segments. Vertebral displacement was estimated with a method described by À. White è Ì. Panjabi [21]. The instability of the spinal motion segment was interpreted at values of 5 points and more.
MSCT was conducted for all patients to clarify the stability of the metal construct, presence of resorption foci in bone tissue in implant-bone contact site, as well as to determine the criteria of spondylodesis and compressing influence on neural structures of the spinal canal. MRI is not enough informative for estimation of these values owing to presence of artefacts of metal elements, and it is contraindicated for patients with cardiac stimulator. MRI is conducted for all patients for estimation of degenerative dystrophic changes in the intervertebral disk according to the classification by C. Pfirrmann [22], and for assessment of reactive changes in subchondral part of vertebral bodies according to the classification by M. Modic [23]. Spondyloarthrosis of facet joints was estimated with the improved classification by D. Weishaupt [24].
Diagnosis of recurrent spinal canal stenosis was based on the clinical picture with dominating root pain syndrome and/or neurogenic intermittent claudification, and with radiologic data. Central stenosis was estimated with the classification by Schizas et al., which is based on estimation of distribution of spinal fluid, cauda equina roots, epidural fibers on T2-weighted axial MRI images [25]. Lateral stenosis was estimated with the classification by Bartynski et al.: the degree 1 –deformation of lateral recess in comparison with the contralateral side; the degree 2 – deformation of the root with presence of focus of liquor; the degree 3 – rough compression with obliteration of liquor spaces [26]. The classification by S. Lee et al. [27] was used for diagnosis of foraminal stenosis, where the degree 1 is obliteration of epidural fat tissue on both sides from the root in the intervertebral foramina on sagittal scans in T1VI MRI; the degree 2 – obliteration of epidural fat tissue on all sides from the root, but without morphological changes; degree 3 –obliteration with morphological changes. Pseudoarthrosis was estimated with presence of the bone block according to the recommendation by Choudhri T.F. et al. [28].
The appropriate bone block was acknowledged in presence of at least single continuous bone bridge between vertebral bodies through the interbody implant and around it. In the opposite case, inconsistency of formation of the bone block was acknowledged. At the same time, the condition of the fixing system was estimated: the fixing system was unstable in presence of a bilateral fracture of longitudinal rods at the single level, or a fracture of both screws at least in one vetebrae and/or presence of osteolysis around both screws at least in one vertebrae.
In the group 1 of patients, in case of clinically significant stenosis, the most important thing was adequate decompression of vascular and neural structures of the spinal canal, spondylodesis with TLIF – 14 (53.8) cases. Decompression was conducted for adjacent segment disease, spondylodesis and prolongation of fixation – in 4 (15.4 %) cases, total discectomy and spondylodesis – in 8 (30.8 %) cases.
In the group 2, patients with pseudoarthrosis received ALIF in combination with transpedicular fixation in 9 (37.6 %) cases. It was determined by technical difficulties because of impossibility of change of the interbody cage, including 10 (41.6 %) – for recurrent disk hernia, and 5 (20.8 %) cases – for spinal canal stenosis determined by migration of the cage. The figure 2 shows a clinical example. The table 2 shows the distribution of patients in dependence on a cause of revision surgery.
Table 2
Distribution of patients in dependence on cause of revision surgery
|
|
Recurrent stenosis |
Recurrent disk hernia |
Pseudoarthrosis |
Adjacent segment syndrome |
Total |
|||||
|
abs. |
% |
abs. |
% |
abs. |
% |
abs. |
% |
abs. |
% |
|
|
Group 1 |
14 |
53.8 |
8 |
30.8 |
- |
|
4 |
15.4 |
26 |
100 |
|
Group 2 |
5 |
20.8 |
10 |
41.6 |
9 |
37.6 |
- |
- |
24 |
100 |
|
Total |
19 |
38.0 |
18 |
36.0 |
9 |
18.0 |
4 |
8.0 |
50 |
100 |
Note: group 1 – decompressive stabilizing intervention with TLIF; group 2 – anterior decompression with ALIF in combination with TPF.
Figure 2
The patient, age of 81. Diagnosis: “Pseudoarthrosis, migration of the cage with stenosis of spinal channel at L4-L5. L5 radiculopathy to the left”. VAS – 8, ODI – 60 %: a, b) mark of the cage in channel; c) the cage removed with ALIF; d, e) preparation of bed and installment of autobone; f) CT after 1 year: VAS – 2, ODI –19 %
|
|
|
|
|
|
The results of revision surgical procedures were analyzed in one year after surgery. Pain intensity (< 2 points – high degree) was estimated with VAS. Functional activity and life quality were estimated with Russian version of the Oswestry Disability Index [29]. Vital disorders were minimal for ODI of 0-20 %, moderate – for 20-40 %, intense – for 40-60 %, disabling – for 60-80 %, extremely intense or exaggerated – for 80-100 %. MacNabscore was used.
Description of statistical methods. The study materials were exposed to statistical preparation with parametric and non-parametric analysis. Accumulation, correction and systematization of basic information and, and visualization of results were performed in electronic tables with Microsoft Office Excel 2016. The statistical analysis was conducted with IBM SPSS Statistics v.20 (IBM Corporation). The variance analysis (Kruskal-Wallis test) was used for comparison of two and more groups, followed by paired comparison (Dann test). Mann-Whitney's test was used for comparison of two groups. The presence of a relationship between the studied values was examined with contingency tables (Fisher's exact test). Wilcoxon's test was used for analysis of recurrent changes (over time). P value < 0.05 was considered as statistically significant.
The study corresponds to the standards of Helsinki Declare – Ethical Principles for Medical Research with Human Subjects. The informed consent for data analysis was received.
RESULTS
Recurrent stenosis of spinal canal was the main indication for revision surgery in 19 (38 %) patients. Recurrent disk hernia determined the indications for revision surgery in 18 (36 %) patients. Adjacent segment disease was identified in 4 (8 %) cases. Pseudoarthrosis was the cause for revision surgery in 9 (18 %) patients.
The comparative results of ODI and VAS after surgical treatment are presented in the table 3. The group 2 (ALIF combined with TPF) showed the statistically significant results: presurgical VAS –7.3 ± 1.2, postsurgical VAS – 1.7 ± 0.4, p < 0.001, presurgical ODI – 50.4 ± 11.5, postsurgical ODI – 10.0 ± 4.6, p < 0.001. The group 1 with decompressive stabilizing interventions (TLIF) also showed statistically significant results: presurgical VAS – 7.8 ± 0.8, postsurgical VAS – 2.7 ± 1.6, p < 0.001, presurgical ODI – 56.2 ± 10.2, postsurgical ODI – 20.6 ± 13.9, p < 0.001. However, the comparative analysis showed better VAS and ODI in the group 2 (p < 0.001).
Table 3
Comparative results of ODI and VAS before and after surgical treatment and between groups
|
Features |
Number of patients (%) |
Level of intergroup significance, p* |
|||||
|
|
Group 1 (n = 26) |
Group 2 (n = 24) |
|||||
|
Gender |
before surgery |
after surgery |
p** |
before surgery |
after surgery |
p** |
p > 0.05 |
|
male |
12 (46.2 %) |
|
16 (66,7%) |
|
|
||
|
female |
14 (53.8 %) |
|
8 (33,3%) |
|
|
||
|
Age, Ì ± SD, range (years) |
59.8 ± 14.0 31.0-84.0 |
|
46,9 ±12,3 23,0 - 67,0 |
|
p < 0.01 |
||
|
ODI, Ì ± SD |
56.2 ± 10.2 |
20.6 ± 13.9 |
< 0.001 |
50.4 ± 11.5 |
10.0 ± 4.6 |
< 0.001 |
p < 0.001 |
|
VAS, Ì ± SD |
7.8 ± 0.8 |
2.7 ± 1.6 |
< 0.001 |
7.3 ± 1.2 |
1.7 ± 0.4 |
< 0.001 |
p < 0.01 |
Note: group 1 – decompressive stabilizing intervention with TLIF; group 2 – anterior decompression with ALIF in combination with TPF; * - level of significance of differences according to Mann-Whitney’s U-test; ** - estimation of significance of differences of values before and after treatment according to Wilcoxon’s test.
The results of subjective estimation of revision surgery with MacNab score were mainly positive: 42.30 % of excellent results, 34.60 % of good results and 11.50 % of poor results in the group 1. Poor results were determined by preservation or development of pain syndrome. The group 2 showed 54.10 % of excellent results, 25 % of good results and 16.60 % of satisfactory results. The results are presented in the figure 3.
Figure 3
Results of subjective estimation of revision surgery with MacNab score
The table 4 shows complications of intrasurgical and early postsurgical period after revision surgery. 3 cases (11.5 %) with superficial infection of surgical site were treated with sanitation, opened management of the wound, and antibacterial therapy according to results of bacteriological studies. For a sudden injury to dura matter (3 cases, 11.5 %), a defect was covered with the muscular flap with use of surgical glue Ivisel (Biopharmaceuticals Ltd., Israel). For 2 cases (8.3 %) with iliac vein injuries, the integrity of the injured part was recovered with application of vascular sutures. In the postsurgical period, early activation and anticoagulant therapy were conducted. There were not any signs of venous insufficiency. Transitory retrograde ejaculation was identified in 1 (4.1 %) patient.
Table 4
Results of complications of intrasurgical and postsurgical period in revision surgery
|
Complications |
Revision surgery techniques |
|
|
|
Decompressive stabilizing intervention with TLIF |
Anterior decompression with ALIF and TPF |
|
Non-healing wounds |
3 (11.5 %) |
-
|
|
Durotomy |
3 (11.5 %) |
- |
|
Iliac vein injury |
- |
2 (8.3 %) |
|
Transitory retrograde ejaculation |
- |
1(4.1 %) |
Note: no reliable differences (Fisher’s exact test).
DISCUSSION
According to the literature data, the values of poor results of revision surgery for degenerative dystrophic diseases of the lumbar spine vary from 15 % to 83.9 % [3-30]. In our study, the values of excellent results were 96.40 % of cases, the satisfactory results – 59.60 %. Recurrent disk hernia and subsequent degeneration after discectomy present the common problem with incidence of 2-25 % [31]. This is one of the main causes of revision surgery after primary surgery. In our study, recurrent disk hernia was identified in 36 %. Adjacent segment disease was 8 %. Adjacent segment disease is the natural process for patients with degenerative dystrophic diseases of the spine which is promoted by surgical intervention, which is, however, is not its cause. According to literature data, the values of symptomatic adjacent segment syndrome are 2-30 % [32]. According to some authors, the values of pseudoarthrosis varied from 3 to 56 % [16-17]. In our study, pseudoarthrosis was 18 % which is similar with data in the foreign literature.
According to some authors, ALIF with TPF can be the efficient alternative in revision surgery of the lumbosacral spine [33-34]. The systematic review and metaanalysis were performed for assessment of efficiency of ALIF for treatment of recurrent disk hernia in 7 studies. The mean Oswestry Disability Index (ODI) was 50.5 (95 % CI 26.8-74.2; I² = 99.42 %, p < 0.001). The mean improvement in VAS for back pain was 4.8 % (95 % CI 3.05–6.5; I² = 98.37 %; p < 0.001). The main improvement in VAS for legs was 3.7 (95 % CI 2.7–4.6; I² = 85.57 %; p < 0.001) [35]. According to Ralph J. and Mobbs et al., ALIF as the alternative technique for lumbar pseudoarthrosis after insufficient surgery with TLIF or PLIF showed some excellent differences between presurgical (7.25 ± 0.8) and postsurgical (3.1 ± 2.1) VAS (p < 0.0001). ODI also showed a statistically significant decrease (p < 0.0001). The values of SF-12 were significantly better (p = 0.0001). Totally, 95 % of cases achieved spondylodesis [36]. In our study, ALIF combined with TPF showed some statistically significant results: presurgical VAS – 7.3 ± 1.2, postsurgical VAS – 1.7 ± 0.4, p < 0.001, presurgical ODI – 50.4 ± 11.5, postsurgical ODI – 10 ± 4.6, p < 0.001.
According to Mohammad El-Sh. et al., the comparative analysis of treatment outcomes of pseudoarthrosis with use of TLIF showed significantly better mean VAS (p = 0.001) and ODI (p = 0.001). Complete fusion was 97.7 % in TLIF, 38.1 % – in PLF (p = 0.001) [19]. A separate study of TLIF in treatment of failed back surgery syndrome showed excellent results in 35 (83.3 %) patients, good results – in 4 patients (9.5 %) and satisfactory ones – in 3 patients (7.1 %) [37]. In our study, the values of decompressive stabilizing interventions with TLIF showed statistically significant results: presurgical VAS – 7.8 ± 0.8, postsurgical VAS – 2.7 ± 1.6, p < 0.001, presurgical ODI – 56.2 ± 10.2, postsurgical ODI – 20.6 ± 13.9, p < 0.001.
There are some differences between primary and revision surgery, including changes in tissues, epidural fibrosis with concurrent risk of accidental durotomy, adjacent segment disease after stabilization or instability after extensive laminectomy. The most common intrasurgical complications of revision surgery were ruptures of dura matter due to scarry changes. According to Cammisa et al., dura matter laceration appears in 3.1 % in revision surgery on average [38]. Papavero L. et al. (2015) [39] reported on 14.3 % of durotomy cases in revision surgery, however, without any long term complications. In all cases, dura matter was restored intrasurgically. In our study, dura matter injury was noted in 3 (5.4 %) patients. The incidence of superficial wound infection was 5.4 %. Lots of authors explained this fact with devascularization after primary surgery [40]. It is reported that the incidence of retrograde ejaculation in men after anterior interbody fusion varied from 0.42 to 5.9 % [41]. In our study, transitory retrograde ejaculation was in 1 (4.1 %) case. According to Mobbs R.J. et al., intrasurgical vascular injury in use of ALIF, requiring for primary recovery with suturing, was in 6.6 % [42]. In our case, the external iliac vein injury was observed in 2 patients (8.3 %).
CONCLUSION
ALIF with TPF as the revision surgery technique allows total discectomy for recurrent disk hernia, decreases the time of traction of paraspinal muscles, and causes less postsurgical pain and lower blood loss during surgery, and lower spinal cord and its roots injury after traction. Recurrent posterior approach can lead to higher risk of dura matter rupture, higher removal of the posterior supporting column for approach to disk space, which can be hindered by scar tissue and epidural fibrosis. These complications could be potentially prevented with anterior approach. Moreover, anterior approach to the lumbar spine allows installing the bigger cages with wider contact surface, resulting in correction of lumbar lordosis and recovery of sagittal balance, which is also important in revision surgery for degenerative dystrophic diseases of the lumbosacral spine.
However, ALIF has some risks. One of the main complications is magistral vascular injury and retrograde ejaculation.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.