| Home | E-Submission | Sitemap | Contact Us |  
The Nerve > Volume 9(1); 2023 > Article
Son, Kim, and Lee: Anterior Cage Migration during Transforaminal Lumbar Interbody Fusion: A Case Report and Review of the Literature


Transforaminal lumbar interbody fusion (TLIF) is a popular procedure for patients with lumbar instability with unilateral foraminal stenosis. Many complications can occur during the procedure. However, cage migration during the procedure is rarely reported. Anterior cage migrations can lead to catastrophic consequences due to the possibility of major vessel injuries. Here, we present a 76-year-old male patient whose cage extruded anteriorly during L5-S1 TLIF. Fortunately, he did not experience any life-threatening complications, and the migrated cage was visible just below the iliac vessels’ bifurcation site on computed tomography angiography. As an alternative, an emergency anterior lumbar interbody fusion was successfully performed, and the TLIF cage was removed during this procedure.


Transforaminal lumbar interbody fusion (TLIF) is an effective operative procedure, showing satisfactory results with acceptable risk rates16). It has gained popularity due to its minimal invasiveness, lower blood loss compared to other surgical techniques, and shorter hospitalization period8). Ironically the increase in the popularity of TLIF has also resulted in increased complication rates, including dural tears, nerve root injuries, screw loosening, and cage mispositioning or migration. Here, we present a rare case of the intraoperative anterior extrusion of a fusion cage during TLIF.


A 76-year-old male patient had initially experienced a gradual aggravation of left lower extremity motor weakness and radiating pain in the L5 and S1 dermatome. His imaging workup carried out at a local spine center, showed severe left L4-5 and L5-S1 foraminal stenosis with central disc extrusion and spondylolisthesis at L5-S1 level (Fig. 1, 2). The patient underwent open lumbar microdiscectomy at the L4-5 level and TLIF at the L5-S1 level. Unfortunately, during the cage insertion procedure at the L5-S1 level, anterior migration occurred where the cage disappeared into the abdominal space. The patient was immediately transferred to our hospital for a thorough evaluation and possible emergency surgery. The patient was very stable when he arrived at our emergency room and his initial symptoms had subsided. Imaging workup X-rays and computed tomography angiography (CTA) (Fig. 3) revealed no major vessel injuries, and the lost cage was placed just below the iliac artery bifurcation area. The patient was hemodynamically stable and was sent to the intensive care unit.
With the help of the department of general surgery, anterior lumbar body fusion (ALIF) at L5-S1 was performed the next day to both remove the migrated cage and restore stability to the lumbar spine. In the surgical field, the cage was located in front of the L5-S1 disc space just below the iliac artery bifurcation, and no bleeding or vessel injury was observed (Fig. 4). The cage was removed, and a large ALIF cage was inserted without any complications. Then, the patient was placed in the prone position, and pedicle screws were inserted percutaneously.
Surgery was completed successfully without complications (Fig. 5). The patient was discharged ten days after surgery with no neurological deficits.


TLIF surgery was first introduced in 1982 by Harms and Rolinger6), and it is considered the preferred method of interbody fusion. There are several advantages of TLIF compared to previous conventional methods of spine interbody fusion. TLIF minimizes the possibility of dural and nerve injury since only minimal thecal sac traction is needed for cage entry after the removal of the ipsilateral facet. Also, through the removal of the facet, the problematic foraminal area can be exposed with little difficulty. Another benefit of TLIF is that additional posterolateral fusion is possible since the contralateral laminae and spinous processes are usually preserved4).
However, even with these excellent features of TLIF, critical complications can occur during the procedure. Although rare, as the case presented in this study, one of the most infamous complications is anterior cage migration. Anterior migration during the procedure can occur when the operator is inserting the cage into the disc space. During this process, the surgeon’s excessive curettage and strong impaction can result in an anterior longitudinal ligament (ALL) tear leading to instant anterior migration into the abdominal space. This could lead to major vessel injuries, resulting in catastrophic consequences3). Many studies have reported the risk factors of cage migration, such as old age, low bone quality, small or oversized cages, and rectangularly shaped cages1,7-10,12,13,17,21). However, these factors are usually related to postoperative migration during the follow-up periods after successful surgery9,21). The preservation of the ALL during disc preparation is especially crucial during TLIF. The ALL usually acts as a barrier during the cage insertion process and minimizes the possibility of the cage entering the abdominal space. It attaches firmly to the anterior surface of the vertebrae. It is not strong on the lateral side which makes it more vulnerable to unilateral and oblique disc procedures than other operations11).
There are no guidelines for reoperation due to anterior cage migration. Although it would be reasonable to consider removing a foreign body that has the possibility of becoming an infection source or a possible cause of delayed vessel injury, there are many arguments against the removal of a migrated cage, especially in hemodynamically stable patients1,2,7,10,14,15,19,20) (Table 1).


TLIF is an increasingly popular procedure for lumbar interbody fusion, and it is mostly recommended for patients with unstable unilateral foraminal stenosis. Although TLIF is a common surgical procedure, it has possible severe complications and should not be taken lightly. Cage migration occurs in 1.8% of the patients and among them, anterior cage migration can cause lead to disastrous consequences18). Physicians should always take into account the possibility of anterior migration and try to preserve the ALL during disc preparation to reduce the chance of this critical complication.


No potential conflict of interest relevant to this article was reported.

Fig. 1.
(A) Sagittal T2-weighted magnetic resonance image (MRI) showing left foraminal stenosis at L4-5 level. (B) Axial T2-weighted MRI showing left foraminal stenosis at L4-5 level.
Fig. 2.
(A) Sagittal T2-weighted magnetic resonance image (MRI) showing left severe foraminal stenosis at L5-S1 level. (B) Axial T2-weighted MRI showing central disc protrusion at L5-S1 level.
Fig. 3.
(A) Lateral lumbar X-ray image showing anterior migration of fusion cage. (B) Axial image of abdominal computed tomography angiography showing fusion cage just below iliac artery bifurcation (white arrow).
Fig. 4.
Intraoperative field showing migrated cage above left iliac artery.
Fig. 5.
Successful surgical removal of fusion cage and anterior lumbar interbody fusion.
Table 1.
Complications after the anterior migration of cage in transforaminal lumbar interbody fusion
References Year Complication
Proubasta et al.15) 2002 Compressed major vessels
Yoshimoto et al.20) 2007 Deep vein thrombosis
Cakmak et al.2) 2010 Colon perforation
Pawar et al.14) 2010 IVC injury
Garg et al.5) 2017 Sigmoid colon perforation
Murase et al.11) 2017 IVC injury
Xu and Zheng19) 2017 Left femoral nerve injury following cage extraction
Kumar et al.10) 2021 Potential risk of perforation of major vessels
Aleixo et al.1) 2021 Iliac vein injury

IVC: Inferior vena cava.


1. Aleixo C, Pereira RS, Sousa H, Seabra P, Marinhas J, Santos FL: Iliac vein injury after anterior transforaminal lumbar interbody fusion cage migration. Int J Res Orthop 7:428-430, 2021
crossref pdf
2. Cakmak A, Gyedu A, Kepenekçi I, Ozcan C, Unal AE: Colon perforation caused by migration of a bone graft following a posterior lumbosacral interbody fusion operation: case report. Spine (Phila Pa 1976) 35:E84-E85, 2010
crossref pmid
3. Cavenaghi A, Hoffmann E, Labed P, Chiche L, Koskas F, Davaine JM: Anterior cage migration during spine surgery: An unusual and severe complication. J Vasc Surg Venous Lymphat Disord 9:497-498, 2021
crossref pmid
4. Cole CD, McCall TD, Schmidt MH, Dailey AT: Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches. Curr Rev Musculoskelet Med 2:118-126, 2009
crossref pmid pmc pdf
5. Garg B, Singla A, Batra S, Kumar S: Early migration of bone graft causing sigmoid colon perforation after trans-foraminal lumbar interbody fusion. J Clin Orthop Trauma 8:165-167, 2017
crossref pmid pmc
6. Harms J, Rolinger H: A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author's transl). Z Orthop Ihre Grenzgeb 120:343-347, 1982
crossref pmid
7. Heary RF, Mummaneni PV: Editorial: Vascular injury during spinal procedures. J Neurosurg Spine 24:407-408, 2016
crossref pmid
8. Hee HT, Castro FP, Majd ME, Holt RT, Myers L: Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors. J Spinal Disord 14:533-540, 2001
crossref pmid
9. Jin L, Chen Z, Jiang C, Cao Y, Feng Z, Jiang X: Cage migration after unilateral instrumented transforaminal lumbar interbody fusion and associated risk factors: a modified measurement method. J Int Med Res 48:300060519867828, 2020
crossref pmid pmc pdf
10. Kumar M, Kaucha D, Adsul N, Chahal RS, Kalra KL, Acharya S: Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature. Surg Neurol Int 12:360, 2021
crossref pmid pmc
11. Murase S, Oshima Y, Takeshita Y, Miyoshi K, Soma K, Kawamura N, et al.: Anterior cage dislodgement in posterior lumbar interbody fusion: a review of 12 patients. J Neurosurg Spine 27:48-55, 2017
crossref pmid
12. Oh HS, Lee SH, Hong SW: Anterior dislodgement of a fusion cage after transforaminal lumbar interbody fusion for the treatment of isthmic spondylolisthesis. J Korean Neurosurg Soc 54:128-131, 2013
crossref pmid pmc
13. Park MK, Kim KT, Bang WS, Cho DC, Sung JK, Lee YS, et al.: Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J 19:437-447, 2019
crossref pmid
14. Pawar UM, Kundnani V, Nene A: Major vessel injury with cage migration: surgical complication in a case of spondylodiscitis. Spine (Phila Pa 1976) 35:E663-E666, 2010
crossref pmid
15. Proubasta IR, Vallvé EQ, Aguilar LF, Villanueva CL, Iglesias JJ: Intraoperative antepulsion of a fusion cage in posterior lumbar interbody fusion: a case report and review of the literature. Spine (Phila Pa 1976) 27:E399-E402, 2002
crossref pmid
16. Rosenberg WS, Mummaneni PV: Transforaminal lumbar interbody fusion: technique, complications, and early results. Neurosurgery 48:569-575, 2001
crossref pmid pdf
17. Smith AJ, Arginteanu M, Moore F, Steinberger A, Camins M: Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages. J Neurosurg Spine 13:388-393, 2010
crossref pmid
18. Tormenti MJ, Maserati MB, Bonfield CM, Gerszten PC, Moossy JJ, Kanter AS, et al.: Perioperative surgical complications of transforaminal lumbar interbody fusion: a single-center experience. J Neurosurg Spine 16:44-50, 2012
crossref pmid
19. Xu Z, Zheng Y: Anterior dislocation of fusion cage after minimal invasive transforaminal lumbar interbody fusion (MI-TLIF): A case report. Biomed Res (Aligarh) 28:7834-7836, 2017

20. Yoshimoto H, Sato S, Nakagawa I, Hyakumachi T, Yanagibashi Y, Nitta F, et al.: Deep vein thrombosis due to migrated graft bone after posterior lumbosacral interbody fusion. Case report. J Neurosurg Spine 6:47-51, 2007
crossref pmid
21. Zhao FD, Yang W, Shan Z, Wang J, Chen HX, Hong ZH, et al.: Cage migration after transforaminal lumbar interbody fusion and factors related to it. Orthop Surg 4:227-232, 2012
crossref pmid pmc
Editorial Office
Department of Neurosurgery, Dankook University Hospital
201, Manghyang-ro, Dongnam-gu, Cheonan-si, Chungcheongnam-do 31116, South Korea
TEL: +0082-41-550-6280   FAX: +82-41-556-0524   
E-mail: spine1225@naver.com , mousehunt7@naver.com
About |  Browse Articles |  Current Issue |  For Authors and Reviewers
Copyright © The Korean Society of Peripheral Nervous System.                 Developed in M2PI