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Updated: Mar 28, 2026
Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion
Published on: August 6, 2019
The Impact of CT-based Subsidence Assessment on Radiographic and Clinical Outcomes After Transforaminal Lumbar
Caden J Messer1, Hannah A Levy1, Zachariah W Pinter1
1Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
Study Design:
Retrospective cohort.
Objective:
This study aims to assess the effects of CT-based subsidence on lumbar sagittal alignment and patient-reported outcome measures (PROMs) after transforaminal lumbar interbody fusion (TLIF), and to determine if subsidence and cage properties are independent predictors of postoperative changes in regional lordosis.
Summary Of Background Data:
Subsidence is a well-known complication following interbody fusion and has previously been associated with recurrence of preoperative symptoms and higher reoperation rates. There is incomplete evidence to characterize the effects of subsidence on lumbar alignment and PROMs following TLIF.
Methods:
All adult patients who underwent 1- or 2-level TLIF at a multi-institutional academic center between 2017 and 2019 were retrospectively identified. Interbody subsidence at the superior and inferior endplate of each TLIF level was directly measured on both coronal and sagittal CT scans obtained between 6 months and 1 year postoperatively. Patients were grouped based on the maximum subsidence at each operative level: mild-moderate (<4 mm) or severe (≥4 mm). Preoperative, immediate (<3 mo), and intermediate (>6 mo) postoperative radiographic outcomes (local and global lumbar alignment) and PROMs (VAS Back, Oswestry Disability Index, PROMIS Physical Function and Mood) were collected. Univariate and multivariate analysis compared patient demographics, surgical factors, and changes in radiographic measures and PROMs across subsidence groups. Multiple linear regression analyzed independent effects of subsidence and cage characteristics on alignment.
Results:
Sixty-seven patients with 85 unique fusion levels were included (55 with mild-moderate subsidence, 30 with severe subsidence). Levels with severe subsidence demonstrated significantly less regional lordosis at final follow-up than nonseverely subsided levels (6.4 vs. 9.1 degrees, P =0.032). No PROM significantly differed between severe and nonsevere subsidence subgroups. Linear regression analysis revealed that severe subsidence was a strong independent predictor of regional lordosis ( P =0.029) at final follow-up.
Conclusions:
Severe subsidence negates perioperative improvements in regional lordosis following TLIF, while changes in regional alignment are maintained in the absence of severe subsidence.
Level Of Evidence:
Level III.
