Anterior Lumbar Interbody Fusion (ALIF) or Transforaminal Lumbar Interbody Fusion (TLIF) for Fusion Surgery in L5/S1 - What Is the Best Way to Restore a physiological Alignment?

Incidence of intraoperative morbidities in anterior lumbar interbody fusion (ALIF): a comprehensive study of 5,299 levels

CONTEXT

Anterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure.

OBJECTIVE

This study evaluates the operative parameters of this procedure based on a substantial number of cases.

STUDY DESIGN

A retrospective case series.

METHODS

Patient data were retrospectively collected from the database of the Instituto de Acessos à coluna Aécio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed.

RESULTS

A total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87 ± 12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%).

CONCLUSIONS

ALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature.

Single-Level Anterolateral and Posterior Interbody Fusion Techniques are Associated With Equivalent Long-Term Lumbar Reoperations

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study compares reoperation rates and complications following single-level anterior lumbar interbody fusion (ALIF)/lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF)/posterior lumbar interbody fusion (PLIF).

SUMMARY OF BACKGROUND DATA

ALIF, LLIF, TLIF, and PLIF are widely used for degenerative disc disease. Lumbar interbody fusions have high rates of reoperation, primarily related to adjacent segment pathology and pseudarthrosis.

MATERIALS AND METHODS

The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF/PLIF with same-day, single-level posterior instrumentation. ALIF/LLIF were combined, and similarly, TLIF/PLIF were combined, given how these operations are indistinguishable from Current Procedural Terminology coding. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms before surgery. The two cohorts, ALIF/LLIF and TLIF/PLIF, were matched 1:1 based on age, sex, Elixhauser-comorbidity index, smoking status, and diabetes. The primary outcome was the incidence of all-cause subsequent lumbar operations. Secondary outcomes included 90-day surgical complications.

RESULTS

After 1:1 matching, each cohort contained 14,070 patients. All-cause subsequent lumbar operations were nearly identical at five-year follow-up (9.4% ALIF/LLIF vs. 9.5% TLIF/PLIF, P =0.91). Survival analysis using all-cause subsequent lumbar operations as the endpoint showed an equivalent 10-year survival rate of 86.0% (95%CI: 85.2-86.8). Within 90 days, TLIF/PLIF had more infections (1.3% vs. 1.7%, P =0.007) and dural injuries (0.2% vs. 0.4%, P =0.001). There was no difference in wound dehiscence, hardware complications, or medical complications.

CONCLUSION

As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long-term reoperation rates.

TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for the treatment of degenerative stenosis and spondylolisthesis.

SUMMARY OF BACKGROUND DATA

ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications.

METHODS

A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010 and 2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery, and secondary outcomes were all-cause medical and surgical complications.

RESULTS

Exact 1:1 matching resulted in 2 equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001) and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P =0.002). All-cause surgical complications were not significantly different between both groups.

CONCLUSION

After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings.

LEVEL OF EVIDENCE

Level-3.

History and Evolution of the Minimally Invasive Transforaminal Lumbar Interbody Fusion

The minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a popular surgical technique for lumbar arthrodesis, widely considered to hold great efficacy while conferring an impressive safety profile through the minimization of soft tissue damage. This elegant approach to lumbar stabilization is the byproduct of several innovations throughout the past century. In 1934, Mixter and Barr's paper in the New England Journal of Medicine elucidated the role of disc herniation in spinal instability and radiculopathy, prompting surgeons to explore new approaches and instruments to access the disc space. In 1944, Briggs and Milligan published their novel technique, the posterior lumbar interbody fusion (PLIF), involving continuous removal of vertebral bone chips and replacement of the disc with a round bone peg. The following decades witnessed several PLIF modifications, including the addition of long pedicle screws. In 1982, Harms and Rolinger sought to redefine the posterior corridor by approaching the disc space through the intervertebral foramen, establishing the transforaminal lumbar interbody fusion (TLIF). In the 1990s, lumbar spine surgery experienced a paradigm shift, with surgeons placing increased emphasis on tissuesparing minimally invasive techniques. Spurred by this revolution, Foley and Lefkowitz published the novel MIS-TLIF technique in 2002. The MIS-TLIF has demonstrated comparable surgical outcomes to the TLIF, with an improved safety profile. Here, we present a view into the history of the posterior-approach treatment of the discogenic radiculopathy, culminating in the MIS-TLIF. Additionally, we evaluate the hallmark characteristics, technical variability, and reported outcomes of the modern MIS-TLIF and take a brief look at technologies that may define the future MIS-TLIF.