Three-stage anterior lumbar interbody fusion revision surgery for transforaminal lumbar interbody fusion cage retrieval: surgical steps and preliminary results.

Abstract

Revising failed transforaminal lumbar interbody fusion (TLIF) presents significant surgical challenges, primarily due to the presence of dense scar tissue and pre-existing cage placement. While anterior surgical approaches offer superior visualization for cage retrieval, existing posterior instrumentation often complicates adequate intervertebral distraction, which is crucial for both comprehensive cage removal and effective deformity correction. Here, we detail a three-stage surgical strategy (back-front-back) adopted in Instituto Quirúrgico Spanò to overcome these inherent limitations. Stage 1 involves the careful removal of existing posterior rods and release of the posterior tension band to re-establish segmental mobility. Stage 2 proceeds with an anterior approach to facilitate the precise removal of the failed interbody cage, meticulous preparation of the endplates, and the subsequent implantation of a new, hyperlordotic anterior lumbar interbody fusion (ALIF) cage, essential for optimal restoration of sagittal alignment. Finally, stage 3 focuses on definitive posterior stabilization using new pedicle screws and rods. To assess the safety and efficacy of this technique, we conducted a retrospective review of 11 consecutive patients who underwent revision surgery, presenting with conditions such as pseudarthrosis, cage subsidence, or sagittal malalignment. The three-stage procedure was technically successful in all 11 patients, with no major complications reported at the one-year follow-up. The mean surgical time recorded was 258 minutes, with an average estimated blood loss of 493 mL. Postoperative imaging studies consistently confirmed satisfactory cage placement in all treated cases, demonstrating the viability and promising outcomes of this comprehensive surgical approach.