Background:

Pseudarthrosis after lumbar fusion can generate pain and disability and often requires revision. However, results of revision procedures have historically been relatively poor.

Questions/purpose:

The aim of this review was to examine the current evidence related to the management of lumbar pseudarthrosis, with a focus on revision after failure of posterolateral fusion or lumbar interbody fusion.

Methods:

A review of orthopedic spine literature published before March 2019 was conducted using PubMed and Google Scholar. Studies addressing revision after failed posterolateral fusions and after failed interbody fusion were selected. We also present a case of successful revision after failed transforaminal lumbar interbody fusion (TLIF).

Results:

The review revealed that persistent pseudarthrosis after revision posterolateral fusion occurs at rates of 35 to 51%. No significant difference has been demonstrated in rates of successful fusion after anterior lumbar interbody fusion (ALIF) and ALIF with revision posterolateral fusion for pseudarthroses after failed TLIF procedures (81% versus 88%), although ALIF alone may be appealing because it avoids further disruption of the posterior musculature. No significant differences have been observed in quality-of-life scores among patients undergoing revision after posterolateral fusion, TLIF, ALIF, or ALIF with posterior fusion. Failed TLIF cages may be extracted and replaced through an anterior or lateral approach. If the geometry of the failed cage permits insertion of a second cage, a contralateral approach may be used. Revision retroperitoneal approaches are associated with higher complication rates.

Conclusions:

The management of lumbar pseudarthrosis requires careful planning, as well as intra-operative attention to detail, for revision surgery to be successful. Circumferential procedures have shown success in revision posterolateral and interbody fusion failures.