Changes in the lumbar foramen following anterior interbody fusion with tapered or cylindrical cages

Abstract 

Background context

Anterior lumbar interbody fusion (ALIF) using both cylindrical and tapered threaded interbody cages has been shown to restore disc height, reduce segmental motion, and relieve low back pain. The effectiveness of these stand-alone cage designs in restoration and maintenance of intervertebral foraminal dimensions has received little attention.

Purpose

To investigate the effects of anterior implantation of cylindrical and tapered interbody cages on morphologic changes of the lumbar neuroforamen and maintenance of foraminal dimensions under dynamic loading.

Study design/setting

A biomechanical study using bovine calf spine model to compare the deformation of foraminal space after ALIF with either tapered cages or cylindrical cages.

Methods

Sixteen fresh calf spines were randomly assigned to undergo ALIF at the L3–L4 level using either two threaded cylindrical or two tapered cages. Lumbar spines were subjected to unconstrained loading in flexion, extension, and lateral bending. Rotation of the L3–L4 segment and dynamic deformation in foraminal height were obtained through a motion analysis system, and compared between the two cage groups. Foraminal dimensions were assessed before and after tapered or cylindrical cage implantation with digitized measurement of bilateral foraminal molds.

Results

Regardless of cage design, anterior implantation of cages increased neuroforaminal area by 17% (p=.0005) and increased the foraminal height by 9% (p=.0004) in the neutral unloaded position. In dynamic loading conditions, foraminal height was significantly stabilized in all loading directions by the cylindrical cages (p=.01) and on both sides during lateral bending by the tapered cages (p<.03). Foraminal stabilization provided by either cage was most prominent in the direction of lateral bending (26–37% of the intact values), while cylindrical cages also provided substantial stabilization in flexion (26% of the intact value). Significant linear relationships were found between foraminal height and residual fusion segment motion under dynamic loading conditions.

Conclusion

Results from this bovine model biomechanical study indicate that stand-alone anterior interbody fusion cages with either tapered or cylindrical design are effective in restoring neuroforaminal height and stabilize the spine to withstand foraminal deformation during daily loading. The degree of stabilization was influenced substantially by the loading direction, to a lesser degree by the cage type, and was strongly dependent on the segment mobility. Although bovine lumbar spine is widely accepted for comparative studies, direct clinical interpretation should be made with caution owing to the anatomical differences from human.

Keywords: Lumbar spine, Interbody fusion, Threaded cages, Neuroforaminal space, Biomechanics