Graft subsidence as a predictor of revision surgery following stand-alone lateral lumbar interbody fusion

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF. METHODS A retrospective review of prospectively collected data was conducted on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria, and compared between those who required revision surgery and those who did not. Additional variables recorded included levels fused, DEXA (dual-energy x-ray absorptiometry) T-score, body mass index, and routine demographic information. The data were analyzed using the Student t-test, chi-square analysis, and logistic regression analysis to identify potential confounding factors. RESULTS Of 297 patients, 34 (11.4%) had radiographic evidence of subsidence and 18 (6.1%) required revision surgery. The median subsidence grade for patients requiring revision surgery was 2.5, compared with 1 for those who did not. Chi-square analysis revealed a significantly higher incidence of revision surgery in patients with high-grade subsidence compared with those with low-grade subsidence. Seven of 18 patients (38.9%) requiring revision surgery suffered a vertebral body fracture. High-grade subsidence was a significant predictor of the need for revision surgery (p < 0.05; OR 12, 95% CI 1.29-13.6), whereas age, body mass index, T-score, and number of levels fused were not. This relationship remained significant despite adjustment for the other variables (OR 14.4; 95% CI 1.30-15.9). CONCLUSIONS In this series, more than half of the patients who developed graft subsidence following stand-alone LLIF required revision surgery. When evaluating patients for LLIF, supplemental instrumentation should be considered during the index surgery in patients with a significant risk of graft subsidence.