Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages

The authors conducted a study to determine at what stage after surgery the subsidence occurred, and to assess the relationships of radiographic fusion and the recurrence of symptoms with the development of subsidence. Ninety patients underwent a single-level anterior lumbar interbody fusion (ALIF) using paired stand-alone rectangular cages between November 2000 and June 2002. All patients had regular clinical or imaging follow-up for a minimum of 19 months (range 19-38 months, mean = 27 months). The ratio of male to female patients was 1:3.1. The patients' ages at the time of ALIF ranged from 25 to 72 years, with a mean of 53 years. The preoperative and postoperative intervertebral disc heights were serially measured by plain radiographs. The location of cage subsidence into the vertebral body and times until the presence of subsidence were also assessed. The mean preoperative intervertebral disc height was 11.6+/-3.1 mm, which spread immediately after surgery to 16.9+/-2.0 mm. This increase was statistically significant (P = 0.001). At the last follow-up visit, the mean intervertebral disc height had been reduced to 13.2+/-2.4 mm. Sixty-nine of 90 patients (76.7%) developed cage subsidence into the surrounding vertebral body. Subsidence was more often noted in the superior endplate above the cage with regard to the location of cage subsidence [superior endplate: 27 patients (39.1%), inferior endplate: 12 patients (17.3%), both: 30 patients (43.6%)]. The onset of subsidence varied from 0.25 to 8 months after surgery (median, 2.75 months). The 8-, 12-, and 16-week actuarial rates for developing cage subsidence were 38.9, 63.4, and 70.7%, respectively, when using the Kaplan-Meier method. There was no statistical correlation between the recurrence of symptoms (P = 0.3952) and radiographic fusion (P = 0.9518) with the log-rank test in development of subsidence. This study demonstrates that cage subsidence is an expected occurrence after ALIF using stand-alone rectangular cages. The 3- and 4-month actuarial rates for developing cage subsidence were 63.4 and 70.7%, respectively, and cage subsidence had no correlation with recurrence of symptoms and radiographic fusion in our study.