title: Incidence of graft extrusion following minimally invasive transforaminal lumbar interbody fusion.
abstract: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been scrutinized for having a complex learning curve. Careful assessment of MI-TLIF complications and critical analyses of prevention may aid a safe adoption of this technique. The current report focuses on the incidence of interbody cage extrusions following MI-TLIF in a series of 513 patients. The authors discuss their experience with graft extrusions and provide methods to minimize this complication. This study retrospectively reviewed 513 prospectively followed patients who underwent MI-TLIF over a 10 year period. The inclusion criteria consisted of all patients who underwent one to three level MI-TLIF, from whom the incidence of cage extrusion was analyzed. Cage extrusion was defined as an interbody graft migrating outside the cephalad and caudal vertebral body posterior margin. Cage extrusions were diagnosed by comparing the intraoperative radiographs to the postoperative radiographs. Patients with >10° coronal curves, significant sagittal malalignment, infection, and preoperative instrumentation failure were excluded. Of 513 patients undergoing MI-TLIF, five patients (0.97%) were diagnosed with cage migrations. The mean follow-up duration was 13.6 ± standard deviation of 8.8 months. Complications included asymptomatic cage migration alone (two patients) neurological decline (two patients) and epidural hematoma (one patient). On average, cage migrations cost a university hospital an additional $US17,217 for revision treatment. While the incidence of cage migrations is low (0.97%), it can lead to postoperative complications that require revision surgery and increased hospital costs. The risk for this significant complication can be minimized with proper technique and patient selection.
authors.affiliation: Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
authors.forename: Joshua
authors.initials: J
authors.lastname: Bakhsheshian
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Khanna
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Winward
authors.initials: W
authors.lastname: Choy
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Cort D
authors.initials: CD
authors.lastname: Lawton
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Alex T
authors.initials: AT
authors.lastname: Nixon
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Albert P
authors.initials: AP
authors.lastname: Wong
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Tyler R
authors.initials: TR
authors.lastname: Koski
authors.affiliation: Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
authors.forename: John C
authors.initials: JC
authors.lastname: Liu
authors.affiliation: Section of Neurological Surgery, Advocate Illinois Masonic, Chicago, IL, USA.
authors.forename: John K
authors.initials: JK
authors.lastname: Song
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Nader S
authors.initials: NS
authors.lastname: Dahdaleh
authors.affiliation: Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Smith
authors.affiliation: Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA. Electronic address: rfessler@rush.edu.
authors.forename: Richard G
authors.initials: RG
authors.lastname: Fessler
mesh_terms: D000368:Aged; D005260:Female; D005548:Foreign-Body Migration / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology*; D012086:Reoperation; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000009:adverse effects* / Q000379:methods*
keywords: Cage; Extrusion; Graft; MI-TLIF; Migration; TLIF