The Association Between Endplate Changes and Risk for Early Severe Cage Subsidence Among Standalone Lateral Lumbar Interbody Fusion Patients

Spine (Phila Pa 1976). 2020 Dec 1;45(23):E1580-E1587. doi: 10.1097/BRS.0000000000003668.


Study design: Retrospective case series.

Objective: The aim of this study was to investigate the association of Modic type endplate changes with the risk of severe subsidence after standalone lateral lumbar interbody fusion (SA-LLIF).

Summary of background data: It has been reported that certain endplate radiolographic features are associated with higher regional bone mineral density (BMD) in the adjacent vertebrae in the lumbar spine. It remains unclear whether these changes have protective effects against osteoporotic complications such as cage subsidence after lumbar surgery.

Methods: We reviewed patients undergoing SA-LLIF from 2007 to 2016 with a follow-up >6 months. Cage subsidence was assessed utilizing the grading system by Marchi et al. As potential contributing factors for cage subsidence, we measured the endplate volumetric BMD (EP-vBMD) and the standard trabecular volumetric BMD measurement in the vertebral body. Modic changes (MC) on magnetic resonance imaging were measured as a qualitative factor for endplate condition. Univariate analysis and multivariate logistic regression analyses with a generalized mixed model were conducted.

Results: Two hundred six levels in 97 patients were included in the final analysis. Mean age (± SD) was 66.7 ± 10.7. Sisty-sdpercent of the patients were female. Severe subsidence was observed in 66 levels (32.0%). After adjusting for age, bone morphogenetic protein (BMP) use, and number of levels fused, the presence of MC type 2 was significantly associated with lower risk of severe subsidence (OR = 0.28 [0.09-0.88], P = 0.029). Whereas, EP-vBMD did not demonstrate a statistical significance (p = 0.600).

Conclusion: The presence of a Modic type 2 change was significantly associated with lower odds of severe subsidence after SA-LLIF. Nonetheless, this significant association was independent from regional EP-vBMD values. This finding suggests that microstructural and/or material property changes associated with Modic type 2 changes might have a protective effect in this patient population.

Level of evidence: 4.

MeSH terms

  • Aged
  • Female
  • Humans
  • Lumbar Vertebrae / surgery*
  • Lumbosacral Region / surgery*
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Retrospective Studies
  • Spinal Fusion / methods*
  • Tomography, X-Ray Computed