In vitro comparison of endplate preparation between four mini-open interbody fusion approaches

Discectomy and endplate preparation are important steps in interbody fusion for ensuring sufficient arthrodesis. While modern less-invasive approaches for lumbar interbody fusion have gained in popularity, concerns exist regarding their ability to allow for adequate disc space and endplate preparation. Thus, the purpose of this study was to quantitatively and qualitatively evaluate and compare disc space and endplate preparation achieved with four less-invasive approaches for lumbar interbody fusion in cadaveric spines.

A total of 24 disc spaces (48 endplates) from L2 to L5 were prepared in eight cadaveric torsos using mini-open anterior lumbar interbody fusion (mini-ALIF), minimally invasive posterior lumbar interbody fusion (MAS PLIF), minimally invasive transforaminal lumbar interbody fusion (MAS TLIF) or minimally invasive lateral, transpsoas interbody fusion (XLIF) on two specimens each, for a total of six levels and 12 endplates prepared per procedure type. Following complete discectomy and endplate preparation, spines were excised and split axially at the interbody disc spaces. Endplates were digitally photographed and evaluated using image analysis software. Area of endplate preparation was measured and qualitative evaluation was also performed to grade the quality of preparation.

The XLIF approach resulted in the greatest relative area of endplate preparation (58.3 %) while mini-ALIF resulted in the lowest at 35.0 %. Overall, there were no differences in percentage of preparation between cranial and caudal endplates, though this was significantly different in the XLIF group (65 vs 52 %, respectively). ALL damage was observed in 3 MAS TLIF levels. Percentage of endplate that was deemed to have complete disc removal was highest in XLIF group with 90 % compared to 65 % in MAS TLIF group, 43 % in MAS PLIF, and 40 % in mini-ALIF group. Endplate damage area was highest in the MAS TLIF group at 48 % and lowest in XLIF group at 4 %.

These results demonstrate that adequate endplate preparation for interbody fusion can be achieved utilizing various minimally invasive approach techniques (mini-ALIF, MAS TLIF, MAS PLIF, XLIF), however, XLIF appears to provide a greater area of and more complete endplate preparation.