Technical Consideration for TLIF Cage Retrieval and Deformity Correction With Anterior Interbody Fusion in Lumbar Revision Surgeries

IntroductionSymptomatic pseudoarthrosis after transforaminal lumbar interbody fusion (TLIF) could result in sagittal malalignment. Revision posterior surgery with TLIF cage removal poses a challenge intraoperatively. The authors have proposed salvage anterior approach for cage removal and have discussed unique experience with the correction in their deformity patients.MethodsAll patients with symptoms of clinical deformity or symptomatic pseudoarthrosis operated from January of 2012 to February of 2018 were included in the study. TLIF cage removal followed by anterior lumbar interbody fusion (ALIF) surgery was performed in all patients. Radiographic sagittal parameters including thoracic kyphosis (TK; T4-T12), sagittal vertical axis (SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), the mismatch between pelvic incidence (PI) and LL (PI-LL), sacral slope (SS), pelvic tilt (PT), and PI were analyzed.Results6 patients (mean age of 57 years, 83% female) underwent TLIF retrieval through anterior approach and ALIF with hyperlordotic cages (HLCs), followed by posterior spinal fusion surgery. Described technique entails use of tailored instruments with sequential gentle distraction of end plates with TLIF spreader could facilitate in the cage removal. Mean number of interbody levels fused pre as well as post were 1.5. The radiographic sagittal parameters from preoperative versus postoperative standing were as follows: T4-T12 TK, 16 degrees vs. 37.6 degrees; LL, -25 degrees vs. -47.6 degrees; PT, 36 degrees vs. 26 degrees; PI-LL, 35 degrees vs. 12.4 degrees; SVA, 12 degrees vs. 5.6 degrees; and TPA, 44 degrees vs. 25 degrees, with p<.001. Mean number of instrumented level fused were 8.1. Using linear regression analysis, change from pre-to postoperative standing in LL predicted pre-to postoperative change in SVA and TPA for global correction (R= -0.30 and -0.80, respectively).ConclusionsAnterior approach is a suitable technique for TLIF cage removal while preserving the end plates for subsequent optimal interbody fusion at the index level in symptomatic pseudoarthrosis patients or those with clinical deformity. ALIF with HLCs with or without Ponte osteotomy can restore segmental and overall sagittal alignment.