Search

PURPOSE: To assess patients perceptions of their abdominal wall following extensile anterolateral approaches to the thoracolumbar spine for adult spinal deformity (ASD) using validated questionnaires. METHODS: Adults who underwent anterior-posterior thoracolumbar spinal operations to the pelvis for ASD in which the anterior fusion was performed through an extensile anterolateral approach were reviewed. Three questionnaires were administered at least 1 year following surgery and included The Abdominal Core Health Quality Collaborative Survey (AHS-QC), The Patient Scar Assessment Scale (PSAS), and The Anterior Abdominal Incision Questionnaire (AAIQ). RESULTS: Fifty-one patients (80.4% female, median age 65 years) were included. Average follow-up was 2.8 ± 1.7 years. Average number of anterior fusion levels was 3.5 ± 1.4. Patients achieved high satisfaction rates from surgery (74.5%). AAIQ responses included postoperative pain (33.3%), bulging (41.7%), and limitations in daily activities (18.8%) with only 15.7% experienced moderate-severe pain related to their incisions and only 6.3% seeking treatment for their scars. Post-operatively, 63.2% had a neutral or improved self-image of their torso and trunk, while only 10.2% stating it was much worse. Patients overall opinion of their scar compared to their normal skin was very positive [average 2.75 ± 2.93 (10 = worst possible scar)]. Favorable scores were also reported for color difference, stiffness, change in thickness, and irregularity in their abdominal scar compared to normal skin. CONCLUSIONS: Following extensile anterolateral approaches to the thoracolumbar spine for ASD, the majority of patients reported mild pain, mild functional limitations, good cosmesis, and high satisfaction rates with their anterior incisions based on validated questionnaires.

Study Design.: Retrospective cohort study. Objective.: Compare outcomes in patients undergoing one-level or two-level anterior lumbar interbody fusion (ALIF) at L4-S1. Background.: Although ALIF may deliver restoration of lumbar lordosis and improvement in clinical outcomes, it also carries risk of complications including major vascular injury. Whether one-level and two-level ALIF offers similar outcomes is not known. Materials and Methods.: Adults who underwent one-level L4-L5 or L5-S1 ALIF and two-level L4-S1 ALIF at a single academic institution were identified. Patient demographics, procedural characteristics, improvement in spinopelvic alignment, and one-year postoperative patient-reported outcome measures (PROMs) and complications were compared. Multivariate regression analyses, accounting for age, sex, and Charlson comorbidity index (CCI), were also performed. Results.: In total, 158 ALIF patients (111 one-level and 47 two-level) were included, with mean age of 51.4 years, 57.0% female, mean CCI of 1.2, and mean follow-up of 27.0 months. Surgical time (147.3 vs. 124.6 min, P =0.002) and hospital length of stay (3.5​​​ vs. 2.9 d, P =0.036) were higher for two-level ALIF. One-year postoperatively, two-level ALIF patients had more caudal apex of lordosis (P =0.016) and 4.1 mm (P =0.002) and 2.0 mm (P =0.019) higher L4-L5 anterior and posterior disc heights, respectively. PROMs were not statistically different across groups (P >0.05). Finally, two-level ALIF patients were 10.9 times more likely to have in-hospital complications (P =0.040), such as intraoperative vascular injury (11.1% vs. 1.5%, P =0.040) or postoperative ileus (7.4% vs. 0.0%, P =0.027), than one-level ALIF patients. Conclusion.: In this investigation with greater than one-year follow-up, two-level ALIF in the L4-S1 spine had higher procedural time, length of stay, and approach-related complications than one-level ALIF. Although there were minor improvements in alignment with two-level ALIF, PROMs were comparable with improvements from baseline to last follow-up. These findings may help surgeons carefully weigh the risks and benefits of one-level versus two-level ALIF when determining surgical plans for patients. Level of Evidence.: Level IV. [ABSTRACT FROM AUTHOR]

While anterior lumbar interbody fusion (ALIF) is known as an established and safe procedure for treatment of degenerative disc disease, albeit rare, the development of postoperative intra-abdominal or retroperitoneal collection of lymph warrants timely diagnosis and management. This study presents the case of a 62-year-old male who underwent L4–L5 and L5–S1 ALIF and developed a persistent left-sided fluid collection, resulting in a symptomatic retroperitoneal lymphocele confirmed by computed tomography (CT). After percutaneous drainage by interventional radiology (IR), output remained high at 1 liter (L) per day, necessitating sclerotherapy with doxycycline and ethanol. In the absence of improvement, a lymphangiogram demonstrating a persistent lymph leak and glue embolization was performed. Due to refractory symptoms, retroperitoneal exploration with methylene blue dye was utilized for lymphatic mapping, and a lymphatic capillary leak in proximity to the left iliac artery was identified and successfully ligated with resolution of symptoms. With suspected fluid collections following ALIF, confirmation with CT or ultrasound (US) imaging followed by percutaneous drainage and testing of fluid is necessary. In mild cases, drainage alone or nonsurgical chemical sclerotherapy may suffice. In symptomatic refractory cases, localization of the site with lymphangiogram or US-guided injection of methylene blue dye allows for easier identification and definitive management with either transabdominal laparoscopic fenestration or retroperitoneal surgical exploration and ligation. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Cohort Study. Objective: Restoration of lordosis in lumbar fusion reduces low back pain, decreases adjacent segment degeneration, and improves postoperative outcomes. However, the potential effects of changes in segmental lordosis on adjacent-level and global lordosis remain less understood. This study aims to examine the relationships between segmental (SL), adjacent-level, and global lumbar lordosis following L5-S1 Anterior Lumbar Interbody Fusion (ALIF). Methods: 80 consecutive patients who underwent single-level L5-S1 ALIF were divided into 3 groups based on the degree of change (∆) in index-level segmental lordosis: <5° (n = 23), 5°-10° (n = 29), >10° (n = 28). Radiographic parameters measured included global lumbar, segmental, and adjacent level lordosis, sacral slope, pelvic tilt, pelvic incidence, and PI-LL mismatch. Results: Patients with ∆SL 5°-10° or ∆SL >10° both showed significant increases in global lumbar lordosis from preoperative to final follow-up. However, patients with ∆SL >10° showed statistically significant losses in adjacent level lordosis at both immediate postoperative and final follow-up compared to preoperative. When comparing patients with ∆SL >10° to those with ∆SL 5-10°, there were no significant differences in global lumbar lordosis at final follow-up, due to significantly greater losses of adjacent level lordosis in these patients. Conclusion: The degree of compensatory loss of lordosis at the adjacent level L4-L5 correlated with the extent of segmental lordosis creation at the index L5-S1 level. This may suggest that the L4 to S1 segment acts as a "harmonious unit," able to accommodate only a certain amount of lordosis and further increases in segmental lordosis may be mitigated by loss of adjacent-level lordosis. [ABSTRACT FROM AUTHOR]

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: (laparoscopic OR endoscopic) AND (anterior AND lumbar). Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudios metafor package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6-43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9-90.4). Complications occurred in 19.2% (95% CI, 13.4-27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6-11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

Anterior lumbar interbody fusion (ALIF) can be combined with posterior column osteotomies (PCOs) to maximize lordotic correction. This study compares radiographic changes in regional and segmental lordosis in patients undergoing ALIF with and without PCOs. Patients >18 years old who underwent ALIF at 1 or 2 segments at a single institution (January 2014–July 2020) were included. Preoperative and postoperative radiographic parameters were determined, and a propensity-matched analysis was performed. Ninety-nine patients (53 [54%] men) underwent ALIF at 129 levels (mean [SD], 1.3 [0.46] levels; median [range] age, 61 [32–83] years). PCOs were performed in 13 (13%) patients at 19 (15%) segments. PCOs included 13 Schwab grade 1 and 6 grade 2 osteotomies. All measures, including lumbar lordosis, segmental lordosis, disc angle, and neural foramen height, increased significantly after surgery (P ≤ 0.003). In the propensity-matched analysis, PCO was associated with greater increases in lumbar lordosis (14.9° vs. 8.2°, P = 0.02), segmental lordosis (14.0° vs. 9.6°, P = 0.03), and disc angle (15.0° vs. 10.2°, P = 0.046). The change in disc angle more closely approximated the inherent lordosis of the cage when PCO was performed (94% vs. 62%, P = 0.004). Performing PCOs and ALIFs significantly increased the radiographic correction of overall and segmental lordosis in the selected patient cohort. The disc angle achieved with ALIF without PCOs was approximately 60% of the cage lordosis. The addition of PCO allowed for greater segmental compression, enabling the disc angle to reach nearly 100% of the inherent interbody cage lordosis. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective cohort study. Objective. To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery. Background. Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature. Patients and Methods. In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications. Results. Overall mean age was 50.4 years (range: 20--83 yr). The mean estimated blood loss was 91.3 mL (range: 10--2800 mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721 mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group (P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications (P > 0.17). Conclusion. Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery. [ABSTRACT FROM AUTHOR]

Objective: Return to work after spinal surgery is a crucial factor in the recovery process. It can contribute not only to physical rehabilitation but also to psychological well-being. This study aims to evaluate the rate of return to work following elective lumbar spine surgery and identify predictors that predict failure of return to work. Methods: Adult patients who underwent anterior lumbar interbody fusion at two medical centers were retrospectively identified. A standardized telephone interview was conducted for the final analysis to assess the clinical outcomes of these patients. Results: Out of a total of 159 patients, 104 were of working age at the time of the elective surgery. Data were missing for 35 patients, who were thus excluded from the analysis. All patients had a minimum follow-up period of one year. After surgery, 75% of the patients returned to work within a median time of 3 months. Quality of life, back pain, leg pain, and ODI scores, as well as self-reported satisfaction, were significantly better in patients who returned to work (p < 0.05). Tobacco use and previous musculoskeletal surgery were significant predictive factors of failure to return to work. None of the patients who were unemployed prior to surgery returned to work. Conclusions: Our study reveals that 75% of patients returned to work within three months after surgery. The most significant predictor of failure to return to work is being unemployed before surgery. Additionally, preoperative education about postoperative behavior and physical activity could potentially increase the rate. [ABSTRACT FROM AUTHOR]

Purpose: Screwed anterior lumbar interbody fusion (SALIF) alleviates the need for supplemental posterior fixation leading to reduction of perioperative morbidity. Specifically, elderly and multimorbid patients would benefit from shorter operative time and faster recovery but tend to have low bone mineral density (BMD). The current study aimed to compare loosening, defined as increase of ROM and NZ, of SALIF versus transforaminal lumbar interbody fusion (TLIF) under cyclic loading in cadaveric spines with reduced BMD. Methods: Twelve human spines (L4–S2; 6 male 6 female donors; age 70.6 ± 19.6; trabecular BMD of L5 84.2 ± 24.4 mgHA/cm3, range 51–119 mgHA/cm3) were assigned to two groups. SALIF or TLIF were instrumented at L5/S1. Range of motion (ROM) and neutral zone (NZ) were assessed before and after axial cyclic loading (0–1150 N, 2000 cycles, 0.5 Hz) in flexion–extension (Flex–Ext), lateral bending, (LB), axial rotation (AR). Results: ROM of the SALIF specimens increased significantly in all loading directions (p ≤ 0.041), except for left AR (p = 0.053), whereas for TLIF it increased significantly in left LB (p = 0.033) and Flex (p = 0.015). NZ of SALIF showed increase in Flex–Ext and LB, whereas NZ of TLIF did not increase significantly in any motion direction. Conclusions: Axial compression loading caused loosening of SALIF in Flex–Ext and LB, but not TLIF at L5/S1 in low BMD specimens. Nevertheless, Post-cyclic ROM and NZ of SALIF is comparable to TLIF. This suggests that, neither construct is optimal for the use in patients with reduced BMD. [ABSTRACT FROM AUTHOR]

Severe sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data are limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients. Severe adult spinal deformity patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and PROMs at baseline and 6-week postoperative visit were included. Patients were grouped into ALIF (1–2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1–2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs. Among the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores, and radiographic spinopelvic parameters (P > 0.05). However, PSO was performed more often in revision cases (P < 0.001). Following surgery, L4-S1 lordosis correction (P = 0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (P = 0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (P < 0.001) and motor deficits (P = 0.049), and in-hospital ICU admission (P = 0.022) and blood products given (P = 0.004), but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and 6-week PROMs were comparable as well. ALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intraoperative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment. [ABSTRACT FROM AUTHOR]

Lumbar interbody fusion (LIF) is a surgical procedure for treating lumbar spinal stenosis and deformities. It removes a spinal disc and insert a cage or bone graft to promote solid fusion. Extensive research on LIF has been supported by numerous animal studies, which are being developed to enhance fusion rates and reduce the complications associated with the procedure. In particular, the anterior approach is significant in LIF research and regenerative medicine studies concerning intervertebral discs, as it utilizes the disc and the entire vertebral body. Several animal models have been used for anterior LIF (ALIF), each with distinct characteristics. However, a comprehensive review of ALIF models in different animals is currently lacking. Medium-sized and large animals, such as dogs and sheep, have been employed as ALIF models because of their suitable spine size for surgery. Conversely, small animals, such as rats, are rarely employed as ALIF models because of anatomical challenges. However, recent advancements in surgical implants and techniques have gradually allowed rats in ALIF models. Ambitious studies utilizing small animal ALIF models will soon be conducted. This review aims to review the advantages and disadvantages of various animal models, commonly used approaches, and bone fusion rate, to provide valuable insights to researchers studying the spine.

Study Design. Retrospective cohort study. Objective. To compare outcomes in anteriorly placed transforaminal lumbar interbody fusions (TLIFs) and anterior lumbar interbody fusions (ALIFs). Summary of Background Data. TLIF and ALIF are surgical techniques that have become more prevalent in recent years. Although studies have compared the two, none have considered TLIFs with anteriorly placed cages, which may serve as a better comparison to ALIFs. Patients and Methods. Patients undergoing TLIF or ALIF with posterior instrumentation from 2010 to 2020 at a tertiary care institution were retrospectively identified. TLIF cage position was assessed and those with anterior placement were included. Electronic medical records were reviewed to identify patient characteristics and patient-reported outcomes. Radiographic outcomes included posterior disc height (DH), lumbar lordosis (LL), sacral slope, pelvic incidence, and pelvic tilt. Statistical analysis was performed to compare the two groups. Results. Of the 351 patients, 108 had ALIF with posterior instrumentation and 207 had a TLIF. Preoperatively, patients undergoing TLIF had less LL (53.7° vs. 60.6°, P < 0.001), sacral slope (38.3° vs. 43.7°, P < 0.001), and pelvic incidence (60.1° vs. 66.1°, P < 0.001), all of which remained significant at 1-year and long-term follow-up (P < 0.001). The TLIF group had less ΔDH (1.51° vs. 5.43°, P < 0.001), ΔLL (1.8° vs. 2.97°, P = 0.038), and Δsegmental lordosis (0.18° vs. 4.40°, P < 0.001) at 1 year postoperatively. At 2 to 3 years, ΔDH (P < 0.001) and Δsegmental lordosis (P = 0.001) remained significant, but ΔLL (P = 0.695) did not. Patients in the TLIF group had higher Visual Analog Scale-Back scores 1 year postoperatively (3.68 vs. 2.16, P = 0.008) and experienced less improvement in Oswestry Disability Index (-17.1 vs. -28.6, P = 0.012) and Visual Analog Scale-Back (-2.67 vs. -4.50, P = 0.008) compared with patients undergoing ALIF. Conclusions. Our findings suggest that ALIF with posterior instrumentation performed superiorly in radiographic outcomes and patient-reported outcomes compared with anteriorly placed TLIFs. Anteriorly placed TLIF cages may not achieve the same results as those of ALIF cages. [ABSTRACT FROM AUTHOR]

Degenerative diseases of the lumbar spine decrease lumbar lordosis (LL). Anterior lumbar interbody fusion (ALIF) at the L5-S1 disc space improves segmental lordosis, LL, and sagittal balance. This study investigated reciprocal changes in spinopelvic alignment after L5-S1 ALIF. A retrospective chart review identified patients who underwent L5-S1 ALIF with or without posterior fixation at a single institution (November 1, 2016 to October 1, 2021). Changes in pelvic tilt, sacral slope, proximal LL (L1-L4), distal LL (L4-S1), total LL (L1-S1), segmental lordosis, pelvic incidence–LL mismatch, thoracic kyphosis, cervical lordosis, and sagittal vertical axis were measured on preoperative and postoperative radiographs. Forty-eight patients were identified. Immediate postoperative radiographs were obtained at a mean (SD) of 17 (20) days after surgery; delayed radiographs were obtained 184 (82) days after surgery. After surgery, patients had significantly decreased pelvic tilt (15.71° [7.25°] vs. 17.52° [7.67°], P = 0.003) and proximal LL (11.86° [10.67°] vs. 16.03° [10.45°], P < 0.001) and increased sacral slope (39.49° [9.27°] vs. 36.31° [10.39°], P < 0.001), LL (55.35° [13.15°] vs. 51.63° [13.38°], P = 0.001), and distal LL (43.17° [9.33°] vs. 35.80° [8.02°], P < 0.001). Segmental lordosis increased significantly at L5-S1 and decreased significantly at L2-3, L3-4, and L4-5. Lordosis distribution index increased from 72.55 (19.53) to 81.38 (22.83) (P < 0.001). L5-S1 ALIF was associated with increased L5-S1 segmental lordosis accompanied by pelvic anteversion and a reciprocal decrease in proximal LL. These changes may represent a reversal of compensatory mechanisms, suggesting an overall relaxation of spinopelvic alignment after L5-S1 ALIF. [ABSTRACT FROM AUTHOR]

One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1%) reported on the ALIF approach, 22 (31.9%) on the OLIF approach, and 31 (44.9%) on the LLIF approach, 2 of which reported on more than one approach. ALIF articles most commonly calculated the loss of disc height over time with a subsidence threshold of > 2 mm. Most OLIF articles calculated the total amount of cage migration into the vertebral bodies, with a threshold of > 2 mm. LLIF was the only approach in which most articles applied the same method for calculation, namely, a grading scale for classifying the loss of disc height over time. We recommend future articles adhere to the most common methodologies presented here to ensure accuracy and generalizability in reporting cage subsidence. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective cohort study. Objective. (1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). Background. There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes. Patients and Methods. A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. “High-grade” osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width. Results. A total of 70 consecutive patients (32 ALIF and 38 MISTLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months. Conclusion. ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen. [ABSTRACT FROM AUTHOR]

• VR-12 PCS < 30 reported worse baseline mental and physical health and disability. • VR-12 PCS < 30 report greater postoperative improvements in mental/physical health. • At 6 weeks, lesser physical function correlates with worse physical health/PHQ-9. • At 6 weeks, VR-12 PCS < 30 saw better physical health/VR-12 MCS improvement. • VR-12 PCS < 30 saw better physical health/PHQ-9 improvement by final follow-up. • VR-12 PCS < 30 had higher MCID achievement rates for PHQ-9 and ODI. No study has evaluated the preoperative impact of Veterans RAND-12 Physical Composite Score (VR-12 PCS) on anterior lumbar interbody fusion (ALIF) patients. This study examines its influence on physical function, mental health, pain, and disability outcomes. Two cohorts of ALIF patients with preoperative VR-12 PCS scores were formed using a single-surgeon registry: VR-12 PCS < 30 and VR-12 PCS ≥ 30. Demographics, perioperative characteristics, and patient-reported outcome measures (PROMs) were collected. PROMs of VR-12 PCS/Mental Composite Score (MCS), Short Form-12 (SF-12) PCS/MCS, Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale-Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected pre/postoperatively up to 2-years. Demographics, perioperative characteristics, and preoperative PROMs were compared. Intercohort postoperative 6-week/final PROMs and improvements were compared. Of 80 patients, there were 41 in the VR-12 PCS < 30 cohort. Besides VR-12 PCS, VR-12 PCS < 30 patients reported inferior preoperative VR-12 MCS/SF-12 PCS/PROMIS-PF/PHQ-9/ODI scores (p ≤ 0.003, all). At 6-weeks postoperatively, VR-12 PCS < 30 reported inferior VR-12 PCS/SF-12 PCS/PROMIS-PF/PHQ-9 (p ≤ 0.030, all). There was greater improvement up to 6-weeks postoperatively in VR-12 PCS < 30 for VR-12 PCS/MCS and SF-12 PCS (p ≤ 0.020, all). VR-12 PCS < 30 reported superior improvement by final follow-up in VR-12 PCS/SF-12 PCS/PHQ-9 (p ≤ 0.006, all). MCID achievement rates were higher in VR-12 PCS < 30 for PHQ-9 and ODI (p ≤ 0.013, both). VR-12 PCS < 30 patients reported inferior postoperative physical function, mental health, and disability, yet superior magnitude of improvement in physical function and mental health. Rates of clinically meaningful improvement for VR-12 PCS < 30 were greater in mental health and disability. [ABSTRACT FROM AUTHOR]

We assessed the frequency of intraoperative complication rates related to access surgery, operating time, and intraoperative bleeding rates described in the literature for patients undergoing anterior lumbar interbody fusion (ALIF) to evaluate the adverse effects and, thus, help in therapeutic decision making and contribute to future clinical trials. A systematic review was conducted of MEDLINE and Embase databases in March 2023. The main inclusion criteria were adult patients aged >18 years, with no maximum age limit; the use of ALIF; the presence of quantitative data on intraoperative complications; and randomized controlled trials and cohort studies. Vascular and peritoneal injuries were considered primary endpoints. The operative time and intraoperative bleeding rate were secondary endpoints. Reports and case series, case-control series, systematic reviews, and meta-analyses were excluded. Eight studies were included with a total of 2395 patients. We found important quantitative data for future randomized clinical studies involving ALIF surgery, including the rate of vascular lesions (2.79%) and peritoneal lesions (0.37%). In addition to these factors, only 4 of the 8 studies addressed the average surgery time, with a total average of 145.61 minutes. Furthermore, 6 of the 8 articles reported the mean rate of intraoperative bleeding, with a total mean blood loss of 272.75 mL. ALIF is a lumbar spine access technique with low intraoperative complications. Patients with contraindications have a higher risk of complications. Randomized clinical trials are needed to assess the efficacy and safety of the procedure. [ABSTRACT FROM AUTHOR]

Lumbar interbody instrumentation techniques are common and effective surgical options for a variety of lumbar degenerative pathologies. Anterior lumbar interbody fusion (ALIF) has become a versatile and powerful means of decompression, stabilization, and reconstruction. As an anterior only technique, the integrity of the posterior muscle and ligaments remain intact. Adding posterior instrumentation to ALIF is common and may confer benefits in terms of higher fusion rate but could contribute to adjacent segment degeneration due to additional rigidity. Large clinical studies comparing stand-alone ALIF with and without posterior supplementary fixation (ALIF+PSF) are lacking. To compare rates of operative nonunion and adjacent segment disease (ASD) in ALIF with or without posterior instrumentation. Retrospective cohort study. Adult patients (≥18 years old) who underwent primary ALIF for lumbar degenerative pathology between levels L4 to S1 over a 12-year period. Exclusion criteria included trauma, cancer, infection, supplemental decompression, noncontiguous fusions, prior lumbar fusions, and other interbody devices. Reoperation for nonunion and ASD compared between ALIF only and ALIF+PSF. Reoperations were modeled as time-to-events where the follow-up time was defined as the difference between the primary ALIF procedure and the date of the outcome of interest. Crude cumulative reoperation probabilities were reported at 5-years follow-up. Multivariable Cox proportional hazard regression was used to evaluate risk of operative nonunion and for ASD adjusting for patient characteristics. The study consisted of 1,377 cases; 307 ALIF only and 1070 ALIF+PSF. Mean follow-up time was 5.6 years. The 5-year crude nonunion incidence was 2.4% for ALIF only and 0.5% for ALIF+PSF; after adjustment for covariates, a lower operative nonunion risk was observed for ALIF+PSF (HR=0.22, 95% CI=0.06–0.76). Of the patients who are deemed potentially suitable for ALIF alone, one would need to add posterior instrumentation in 53 patients to prevent one case of operative nonunion at a 5-year follow-up (number needed to treat). Five-year operative ASD incidence was 4.3% for ALIF only and 6.2% for ALIF+PSF; with adjustments, no difference was observed between the cohorts (HR=0.96, 95% CI=0.54–1.71). While the addition of posterior instrumentation in ALIFs is associated with lower risk of operative nonunion compared with ALIF alone, operative nonunion is rare in both techniques (<5%). Accordingly, surgeons should evaluate the added risks associated with the addition of posterior instrumentation and reserve the supplemental posterior fixation for patients that might be at higher risk for operative nonunion. Rates of operative ASD were not statistically higher with the addition of posterior instrumentation suggesting concern regarding future risk of ASD perhaps should not play a role in considering supplemental posterior instrumentation in ALIF. [ABSTRACT FROM AUTHOR]

Background: In anterior lumbar interbody fusion (ALIF), the use of integrated screws is attractive to surgeons because of the ease of implantation and no additional profile. However, the number and length of screws necessary for safe and stable implantation in various bone densities is not yet fully understood. The current study aims to determine how important both length and number of screws are for stability of ALIFs. Methods: Three bone models with densities of 10, 15, and 20 pounds per cubic foot (PCF) were chosen as surrogates. These were instrumented using the Z-Link lumbar interbody system with either 2, 3, or 4 integrated 4.5 × 20 mm screws or 4.5 × 25 mm screws (Zavation, LLC, Flowood, MS). The bone surrogates were tested with loading conditions resulting in spine extension to measure construct stiffness and peak force. Results: The failure load of the construct was influenced by the length of screws (p=.01) and density of the bone surrogate (p

BackgroundFor the surgical treatment of single-level degenerative spondylolisthesis (DS), patients can be treated with either an anterior or posterior interbody fusion. Prior studies have shown that patients with symptomatic degenerative spondylolisthesis treated surgically maintain substantially greater pain relief and improvement in function when compared to those treated non-operatively, but no consensus has emerged between which approach results in the best outcomes.MethodsThe PearlDiver MARINER database was queried for patients with single-level DS who underwent either an anterior or posterior lumbar interbody fusion. Both populations were compared on multiple outcomes, including reoperation, post-operative complications, and readmission rates at 90 days, as well as rates of reoperation and cauda equina syndrome two-years postoperatively.ResultsAt 90 days patients who underwent anterior interbody were found to have higher rates of DVT (OR 2.53, 95% CI 1.74 - 3.70, p

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: “(laparoscopic OR endoscopic) AND (anterior AND lumbar).” Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio’s “metafor” package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6–43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9–90.4). Complications occurred in 19.2% (95% CI, 13.4–27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6–11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

Mycobacterium abscessus (M. abscessus) infections primarily affect immunocompromised patients who commonly present with non-orthopedic infections. We present a case of a 63-year-old female presented with persistent back pain and radicular pain. Computed tomography and magnetic resonance imaging showed a large multiloculated anterior epidural abscess. We show here the unique occurrence of lumbar M. abscessus vertebral osteomyelitis, which was treated with L2 and L3 corpectomies, anterior lumbar interbody fusion, and posterior instrumentation via an anterolateral thoracoabdominal (TA) incision. Vascular surgery provided L1–L4 spine exposure via a left anterolateral TA incision, whereas orthopedic surgery performed L2 and L3 corpectomies with lumbar cage placement and posterior instrumentation in two separate procedures. The patient was discharged to a skilled nursing facility, retaining all neurological function, and is progressing well on follow-up. [ABSTRACT FROM AUTHOR]

The main concern in anterior exposure of the lumbosacral spine is the risk of vascular injury during mobilization and retraction of the blood vessels. Preoperative planning is considered essential to reducing the incidence of vascular injury, although no consensus has been reached on the preferred methodology for such planning. This is a retrospective study, including all patients operated on by a single surgeon, who received anterior lumbar-spine surgery in the supine position as a primary procedure before undergoing an anterior lumbar interbody fusion (ALIF) or an artificial disc replacement (ADR). The aim of this study was to list the intraoperative complications observed. We included 156 patients (87 women; mean age, 48 years) who met the inclusion criteria. The overall complication rate was 6.4% (10/156). The most frequent complications were an incidental peritoneal opening (seven patients, 4.4%); two left–iliac-vein injuries (1.28%) that were sutured; and one dural tear during a decompression maneuver of the canal. No neurological, arterial, or ureteral injury or retrograde ejaculation was reported. The use of a sound protocol that includes planning, assessment of approach difficulty, and step-by-step surgical technique can reduce the rate of vascular injury in anterior lumbosacral-spine surgery.

A variety of different lumbar spinal fusion techniques have been developed. In this study, we review published medical literature highlighting the differences between lumbar interbody fusion techniques with regard to their surgical technique, clinical outcomes, and complications. PubMed, ScienceDirect, and Google Scholar searches were performed for studies published between January 1990 to April 2018 reporting spinal fusion surgery clinical outcomes of at least one fusion technique. Clinical outcomes were extracted and pooled by surgical technique. Chi-squared analyses and Fisher Exact Tests were used to determine differences in rates between groups. PLIF had the highest rate of successful fusion (97% [155/159]) and the lowest rate of complications (4% [6/131]). A chi square analysis revealed a significant difference in fusion success in PLIF compared to PLF (84% [278/330], p <.001). PLIF also had significantly fewer complications compared to PSF (14.7% [251/1709], p =.001), PLF (13.4% [47/351], p =.008), ALIF (14.2% [22/155], p =.008), and LIC (13.9% [47/339], p =.005). Additionally, there were significant differences in the rate of successful fusion when comparing lateral interbody cage (LIC) techniques (p =.041), which include OLIF (100% [63/63]), DLIF (92% [24/26]), and XLIF (87% [67/77]). LIC techniques overall had higher fusion success rates (93.0% [154/166] compared to PLF (p =.01), but a higher rate of complications (14% [47/339]) compared to PLIF (p =.005) and TLIF (6% [17/259], p =.005). Overall, PLF and XLIF have the lowest fusion success rates, and OLIF demonstrated a trend of higher fusion rates among LIC. Techniques that utilized interbody fusion tended to increase the rate of fusion. While interbody fusion techniques offer higher rates of fusion, complication rates also tend to rise with the increase in complexity of the surgical technique, as with OLIF which notably has the highest fusion rate and complication rate. [ABSTRACT FROM AUTHOR]

This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes. PubMed, Cochrane, and Google Scholar (pages 1–20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence–LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI). Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF. Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach–related comorbidity. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort Objective: Anterior lumbar interbody fusion (ALIF) may be complicated by subsidence, which can lead to significant morbidity including pain, disc space collapse, neural compression, segmental kyphosis, instability, and vertebral body fracture. This study sought to identify patient and procedural risk factors for subsidence in patients undergoing ALIF. Methods: This study analyzed consecutive patients who underwent ALIF at a single institution with a minimum of 2 years follow-up. Patients were grouped as either Non-Subsidence (NS-ALIF) or Cage Subsidence (CS-ALIF) based on the final postoperative radiograph. Demographic variables, operative characteristics, and radiographic outcomes were evaluated to identify significant predictors on univariate and multivariate statistics. Results: 144 patients (170 levels) were included with an average follow-up of 50.70 ± 28.44 months (4.23 years). The incidence of subsidence was 22.94% (39/170 levels). On univariate statistics, the CS-ALIF group was significantly older (P =.020), had higher BMI (P =.048), worse ASA (P =.001), higher prevalence of comorbid osteoporosis (P <.001), and a more anteriorly placed interbody device (P =.005). On multivariate analysis, anterior cage placement remained the only significant predictor (OR: 1.08, 95% CI: 1.03–1.14; P =.003). There was a significantly higher rate of subsequent adjacent segment surgery among the CS-ALIF group (P =.035). Conclusion: Factors contributing to subsidence in ALIF included older age, higher BMI, severe ASA, and osteoporosis, while anterior cage placement remained the only independent predictor on multivariate analysis. Subsidence was associated with a higher rate of subsequent adjacent segment surgery. Surgical technique should optimize placement of the interbody cage and avoid overstuffing the disc space. [ABSTRACT FROM AUTHOR]

Minimally invasive approaches to the spine via anterior and posterior approaches have been increasing in popularity, culminating in the development of robot-assisted spinal fusions. The da Vinci surgical robot has been used for anterior lumbar interbody fusion (ALIF), with promising results. Similarly, multiple spinal robots have been developed to assist placement of posterior pedicle screws. However, no previous cases have reported on using robots for both anterior and posterior fixation in a single surgery. We present a technical note on the first reported case of a totally robotic minimally invasive anterior and posterior lumbar fusion and instrumentation. A 65-year-old man with chronic low back pain and left greater than right lower extremity radiculopathy was found to have grade 1 spondylolisthesis at L5/S1 that worsened on standing upright. He underwent ALIF using a da Vinci robotic approach, followed by percutaneous posterior instrumented fusion with the Globus Excelsius GPS robot. The patient did well postoperatively, with improvement of back and leg pain at 3 months follow-up. Radiography confirmed appropriate placement of the interbody cage and pedicle screws. All-robotic placement of both ALIF and posterior lumbar pedicle fixation may be safe, feasible, and efficacious. [ABSTRACT FROM AUTHOR]

Background: Lateral lumbar interbody fusion supplemented with insertion of pedicle screws is a surgical procedure that has gained popularity in the last years, becoming an important tool in the armamentarium of spine surgeons. In recent years, there is a trend to complete both procedures in a single position, thus avoiding flipping the patient prone to insert the pedicle screws. Methods: We describe a step-by-step workflow of the robotic-assisted technique for multilevel lateral lumbar interbody fusion supplemented with posterior instrumentation. The surgical procedure is performed in a single lateral position. For access to L4–5 or L5–S1, an oblique abdominal incision is performed in the same position, and the desired disc space is approached through an oblique or anterior corridor in the retroperitoneal space. Conclusion: Robotic-assisted single-position lateral for multilevel circumferential lumbar interbody fusion is a safe and effective procedure in patients where lumbar stabilization is required. This technique provides patients with a faster recovery and low risk of complications. [ABSTRACT FROM AUTHOR]

The main concern in anterior exposure of the lumbosacral spine is the risk of vascular injury during mobilization and retraction of the blood vessels. Preoperative planning is considered essential to reducing the incidence of vascular injury, although no consensus has been reached on the preferred methodology for such planning. This is a retrospective study, including all patients operated on by a single surgeon, who received anterior lumbar-spine surgery in the supine position as a primary procedure before undergoing an anterior lumbar interbody fusion (ALIF) or an artificial disc replacement (ADR). The aim of this study was to list the intraoperative complications observed. We included 156 patients (87 women; mean age, 48 years) who met the inclusion criteria. The overall complication rate was 6.4% (10/156). The most frequent complications were an incidental peritoneal opening (seven patients, 4.4%); two left–iliac-vein injuries (1.28%) that were sutured; and one dural tear during a decompression maneuver of the canal. No neurological, arterial, or ureteral injury or retrograde ejaculation was reported. The use of a sound protocol that includes planning, assessment of approach difficulty, and step-by-step surgical technique can reduce the rate of vascular injury in anterior lumbosacral-spine surgery. [ABSTRACT FROM AUTHOR]

Abstract Backgrounds Anterior lumbar interbody fusion (ALIF) is an attractive option for revision lumbar interbody fusion as it provides wide access for implant removal and accommodation of large interbody grafts for fusion. However, revision lumbar interbody fusion surgery has not been found to result in significantly better functional outcomes compared with other approaches. To date, no prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion have been reported. In this study, we investigated the surgical results and possible prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion. Methods Patients who received revision interbody fusion surgery between January 2010 and May 2018 in our hospital were reviewed. Clinical outcomes were determined according to whether the VAS score improvement in back pain and leg pain reached the minimum clinically important difference (MCID) and Macnab criteria. Radiographic outcomes were assessed with fusion rate, preoperative, and postoperative lumbar lordosis. Operative-relative factors that may affect clinical outcomes, such as BMI, existence of cage migration, cage subsidence, pseudarthrosis, previous procedure, and number of fusion segments, were collected and analyzed. Results A total of 22 consecutive patients who received ALIF for revision interbody fusion surgery were included and analyzed. There were 9 men and 13 women with a mean age at operation of 56 years (26–78). The mean follow-up was 73 months (20–121). The minimal clinically important difference (MCID) was reached in 11 (50%) of the patients for back pain and 14 (64%) for leg pain. According to the modified Macnab criteria, 73% of the patients in this study had successful outcomes (excellent or good). The pain and lumbar lordosis had significant improvement (P

Background Anterior lumbar interbody fusion (ALIF) is an effective surgical technique for treating various lumbar pathologies, but its use in elderly patients is controversial. Data concerning complications and effectiveness are sparse. We investigated peri- and postoperative complications, radiographic parameters, and clinical outcome in elderly patients. Methods Patients ≥65 years who underwent ALIF between January 2008 and August 2020 were included in the study. All surgeries were performed through a retroperitoneal approach. Clinical and surgical data as well as radiologic parameters were collected prospectively and analyzed retrospectively. Results A total of 39 patients were included; the mean age was 72.6 (±6.3) years (range: 65–90 years); and the mean American Society of Anesthesiologists (ASA) risk classification was 2.3 (±0.6). A laceration of the left common iliac vein was the only major complication recorded (2.6%). Minor complications occurred in 20.5% of patients. Fusion rate was 90.9%. Reoperation rate at the index level was 12.8 and 7.7% in adjacent segments. The multidimensional Core Outcome Measures Index (COMI) improved from 7.4 (±1.4) to 3.9 (±2.7) after 1 year and to 3.3 (±2.6) after 2 years. Oswestry disability index (ODI) improved from 41.2 (±13.7) to 20.9 (±14.9) after 1 year and to 21.5 (±18.8) after 2 years. Improvements of at least the minimal clinically important change score of 2.2 and 12.9 points in the ODI and COMI after 2 years were noted in 75 and 56.3% of the patients, respectively. Conclusion With careful patient selection, ALIF is safe and effective in elderly patients. [ABSTRACT FROM AUTHOR]

Study Design: Single-center retrospective cohort study Objectives: To evaluate inpatient MME administration associated with different lumbar spinal fusion surgeries Methods: Patients ≥18 years of age with a diagnosis of Grade I or II spondylolisthesis, stenosis, degenerative disc disease or pars defect who underwent one-level Transforaminal Lumbar Interbody Fusion (TLIF) or one-level Anterior Lumbar Interbody Fusion (ALIF) or Lateral Lumbar Interbody Fusion (LLIF) through traditional MIS, anterior-posterior position or single position approaches between L2-S1. Outcome measures included patient demographics, surgical procedure and approach, perioperative clinical characteristics, incidence of ileus and inpatient MME. Statistical analysis included one-way ANOVA with a post-hoc Tukey Test and Kruskal–Wallis Test with post-hoc Mann–Whitney test. MME was calculated as per the Centers for Medicare and Medicaid Services and previous literature. Significance set at P <.05. Results: Mean age differed significantly between MIS TLIF (55.6 ± 12.5 years) and all other groups (Open TLIF 57.1 ± 12.5, SP ALIF/LLIF 57.9 ± 9.9, TP ALIF/LLIF 50.9 ± 12.7, Open ALIF/LLIF 58.4 ± 15.5). MIS TLIF had the shortest LOS compared to all groups except SP ALIF/LLIF. Total MME was significantly different between MIS TLIF and Open ALIF/LLIF (172.5 MME vs 261.1 MME, P =.044) as well as MIS TLIF and TP ALIF/LLIF (172.5 MME vs 245.4 MME, P =.009). There were no significant differences in MME/hour and incidence of ileus between all groups. Conclusion: Patients undergoing MIS TLIF had lower inpatient opioid intake compared to TP and SP ALIF/LLIF, as well as shorter LOS compared to all groups except SP ALIF/LLIF. Thus, it appears that the advantages of minimally invasive surgery are seen in minimally invasive TLIFs. [ABSTRACT FROM AUTHOR]

BackgroundAnterior lumbar interbody fusion (ALIF) is commonly utilized in lumbar degenerative pathologies. Standalone ALIF (ST-ALIF) systems were developed to avoid added morbidity, surgical time, and cost of anterior and posterior fusion (APF). Controversy exists in the literature about which of these two techniques yields superior clinical and radiographic outcomes, and few studies have directly compared them. This study seeks to compare ST-ALIF and APF in terms of sagittal correction and surgical complications.MethodsNinty-two consecutive ALIF cases performed from 2013-2018 were retrospectively reviewed and separated into 2 groups. Radiographic measurements were performed on pre- and post-operative radiographs, including segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL). Surgical complications were determined. Statistical analysis was performed using chi-square test of homogeneity, Fisher's exact test, and independent sample t-test. Comparisons between groups were deemed statistically significant at the P

Abstract Background and objective Anterior lumbar interbody fusion (ALIF) and oblique lumbar interbody fusion (OLIF) have shown a great surgical potential, while it has always been controversial which surgical approach and which type of fixation system should be selected. This study investigated the biomechanical response of ALIF and OLIF with various supplementary fixation systems using the finite element method. Materials and methods Lumbar L4–L5 ALIF and OLIF models stabilized by different supplementary fixation systems (stand-alone cage, integrated stand-alone cage, anterior plate, and bilateral pedicle screw) were developed to assess the segmental range of motion (ROM), endplate stress (EPS), and screw-bone interface stress (SBIS). Experimental results ALIF showed lower ROM and EPS than OLIF in all motion planes and less SBIS in the most of motion planes compared with OLIF when the anterior plate or pedicle screw was used. ALIF induced higher ROM, while lower EPS and SBIS than OLIF in the majority of motion planes when integrated stand-alone cage was utilized. Using a stand-alone cage in ALIF and OLIF led to cage migration. Integrated stand-alone cage prevented the cage migration, whereas caused significantly larger ROM, EPS, and SBIS than other fixation systems except for the rotation plane. In the most of motion planes, the pedicle screw had the lowest ROM, EPS, and SBIS. The anterior plate induced a slightly larger ROM, EPS, and SBIS than the pedicle screw, while the differences were not significant. Conclusion ALIF exhibited a better performance in postoperative segmental stability, endplate stress, and screw-bone interface stress than OLIF when the anterior plate or the pedicle screw was used. The pedicle screw could provide the greatest postoperative segmental stability, less cage subsidence incidence, and lower risk of fixation system loosening in ALIF and OLIF. The anterior plate could also contribute to the stability required and fewer complications, while not as effectively as the pedicle screw. Extreme caution should be regarded when the stand-alone cage is used due to the risk of cage migration. The integrated stand-alone cage may be an alternative method; however, further optimization is needed to reduce complications and improve postoperative segmental stability.

Spatial computing (SC) in a surgical context offers reconstructed interactive four-dimensional models of radiological imaging. Preoperative and postoperative assessment with SC can offer more insight into personalized surgical approaches. Spine surgery has benefitted from the use of perioperative SC assessment. Herein, we describe the use of SC to perform a perioperative assessment of a revision spinal deformity surgery. A 79-year-old wheelchair-bound male presented to the neurosurgery clinic with a history of chronic lumbar pain associated with bilateral lower extremity weakness. His surgical history is significant for an L2-L5 lumbar decompression with posterior fixation 1 year prior. On examination, there were signs of thoracic myelopathy. Imaging revealed his previous instrumentation, pseudoarthrosis, and cord compression. We perform a two-staged operation to address the thoracic spinal cord compression and myelopathy, pseudoarthrosis, and malalignment with a lack of global spinal harmony. His imaging is driven by a spatial computing and SC environment and offers support for the diagnosis of his L2-3 and L4-5 pseudoarthrosis on the reconstructed SC-based computed tomography scan. SC enabled the assessment of the configuration of the psoas muscle and course of critical neurovascular structures in addition to graft sizing, trajectory and approach, evaluation of the configuration and durability of the anterior longitudinal ligament, and the overlying abdominal viscera. SC increases the familiarity of the patient's specific anatomy and enhances perioperative assessment. As such, SC can be used to preoperatively plan for spinal revision surgery.

Anterior lumbar interbody fusion (ALIF) is a lumbar arthrodesis technique via an anterior approach that is less invasive than the posterior approaches. However, it is associated with specific pain in the abdominal wall. The objective of this study was to determine whether performing a bilateral ultrasound-guided Transversus abdominis plane (TAP) block allows a reduction in morphine consumption in the first 24 hours after surgery. This study is a prospective single-center, randomized, double-blind study. Patients undergoing ALIF surgery were included and randomized into two groups. Both groups received a TAP block performed at the end of surgery with either ropivacaine or placebo. The primary outcome measure was morphine consumption in the first 24 hours. The main secondary outcomes were immediate postoperative pain and opioid-related side effects. Intra- and postoperative anesthesia and analgesia protocols where standardized. A bilateral ultrasound-guided TAP block was performed with 75 mg (in 15 mL) of ropivacaine per side or isotonic saline serum depending on their assignment group. Forty-two patients were included in the study (21 per group). Morphine consumption at 24 hours (28 mg [18–35] in the ropivacaine group versus 25 mg [19–37] in the placebo group [p=.503]) were not significantly different between the two groups. TAP block with ropivacaine or placebo provided a similar postoperative analgesia when associated with a multimodal analgesia protocol for ALIF. [ABSTRACT FROM AUTHOR]

Purpose: The optimal surgical management of low- and high-grade isthmic spondylolisthesis (LGS and HGS -IS) is debated as well as whether reduction is needed especially for high-grade spondylolisthesis. Both anterior and posterior techniques can be associated with mechanical disadvantages as hardware failure with loss of reduction and L5 injury. We purpose a novel endoscopic-assisted technique (Sled technique, ST) to achieve a complete reduction in two surgical steps: first anteriorly through a retroperitoneal approach to obtain the greatest part of correction and then posteriorly to complete reduction in the same operation. Methods: ST efficacy and complications rate were evaluated through a retrospective functional and radiological analysis. Results: Thirty-one patients, 12 male (38.7%) and 19 female (61.3%), average age: 45.4 years with single level IS underwent olisthesis reduction by ST. Twenty-three IS involved L5 (74.2%), 7 L4 (22.5%) and 1 L3 (3.3%). No intraoperative complications were recorded. One patient required repositioning of a pedicle screw. A significant improvement of functional and radiological parameters (L4-S1 and L5-S1 lordosis) outcomes was recorded (p < 0.001). Conclusion: ST provides a complete reduction in the slippage in LGS and HGS. The huge anterior release as well as the partial reduction in the slippage by the endoscopic-assisted anterior procedure, because of the cage is acting as a "guide rail", facilitate the final posterior reduction, always complete in our series, minimizing mechanical stresses and neurological risks. ClinicalTrials.gov Identifier: NCT03644407. [ABSTRACT FROM AUTHOR]

Background: Anterior lumbar interbody fusion (ALIF) has become an increasingly popular and effective treatment modality for various conditions of the lumbar spine. However, complications after this procedure can be costly. Surgical site infections (SSIs) are one of these types of complications. The present study identifies independent risk factors for SSI after single-level ALIF to identify high-risk patients better. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify single-level ALIF patients from 2005 to 2016. Multilevel fusions and non-anterior approach procedures were excluded. Mann-Pearson χ2 tests analyzed categorical variables, whereas one-way analysis of variance (ANOVA) and independent t-tests analyzed differences in mean values of continuous variables. Risk factors for SSI were identified via a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated utilizing the predicted probabilities. Results: A total of 10,017 patients met inclusion criteria; 80 (0.80%) had developed SSI and 9,937 (99.20%) had not. On multivariable logistic regression models, class 3 obesity (p = 0.014), dialysis (p = 0.025), long-term steroid use (p = 0.010), and wound classification 4 (dirty/infected) (p = 0.002) all independently increased the risk for SSI in single-level ALIF. The area under the receiver operating characteristic curve (AUROC; C-statistic) was 0.728 (p < 0.001), indicating relatively strong reliability of the final model. Conclusions: Several independent risk factors including obesity, dialysis, long-term steroid use, and dirty wound classification all increased risk for SSI after single-level ALIF. By identifying these high-risk patients, surgeons and patients can have more informed pre-operative discussions. In addition, identifying and optimizing these patients prior to operative intervention may help to minimize infection risk. [ABSTRACT FROM AUTHOR]

Study Design.: Retrospective Cohort Study Objective.: The objective of this study was to compare the rate of adjacent segment disease (ASD) between lumbar disk arthroplasty (LDA) and anterior lumbar interbody fusion (ALIF). Summary of Background Data.: LDA and ALIF are alternative surgical approaches used to treat lumbar degenerative disk disease. However, there is a paucity of studies comparing the risk of ASD after these procedures. Methods.: Patients who underwent 1- to 2-level LDA or ALIF between 2010 and 2022 were identified in the PearlDiver Mariner insurance all-claims database. Exclusion criteria included the history of prior lumbar spine surgery or surgery for tumors, trauma, or infection. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors, which were significantly associated with ASD. Results.: 1:1 propensity matching created two equal groups of 1625 patients without baseline differences who underwent LDA or ALIF. LDA was significantly associated with a lower risk of ASD (relative risk: 0.932, 95% CI, 0.899–0.967, P <0.001) and need for revision within 30 days (relative risk: 0.235, 95% CI, 0.079–0.698, P =0.007). There were no differences in all-cause surgical and medical complications between both groups. Conclusions.: After risk adjustment for demographic and clinical characteristics, the results suggest that LDA is associated with a lower risk of ASD compared with ALIF. LDA was also associated with lower hospital cost and shorter length of stay. [ABSTRACT FROM AUTHOR]

Backgrounds: Anterior lumbar interbody fusion (ALIF) is an attractive option for revision lumbar interbody fusion as it provides wide access for implant removal and accommodation of large interbody grafts for fusion. However, revision lumbar interbody fusion surgery has not been found to result in significantly better functional outcomes compared with other approaches. To date, no prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion have been reported. In this study, we investigated the surgical results and possible prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion. Methods: Patients who received revision interbody fusion surgery between January 2010 and May 2018 in our hospital were reviewed. Clinical outcomes were determined according to whether the VAS score improvement in back pain and leg pain reached the minimum clinically important difference (MCID) and Macnab criteria. Radiographic outcomes were assessed with fusion rate, preoperative, and postoperative lumbar lordosis. Operative-relative factors that may affect clinical outcomes, such as BMI, existence of cage migration, cage subsidence, pseudarthrosis, previous procedure, and number of fusion segments, were collected and analyzed. Results: A total of 22 consecutive patients who received ALIF for revision interbody fusion surgery were included and analyzed. There were 9 men and 13 women with a mean age at operation of 56 years (26–78). The mean follow-up was 73 months (20–121). The minimal clinically important difference (MCID) was reached in 11 (50%) of the patients for back pain and 14 (64%) for leg pain. According to the modified Macnab criteria, 73% of the patients in this study had successful outcomes (excellent or good). The pain and lumbar lordosis had significant improvement (P < 0.05). Preoperative fusion segment ≥ 2 was shown to be a poor prognostic factor for back pain improvement reaching MCID (P = 0.043). Conclusions: ALIF has proven effective for revision lumbar fusion surgery, yielding positive clinical and radiographic results. However, having two or more preoperative fusion segments can negatively impact back pain improvement. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis. [ABSTRACT FROM AUTHOR]

Lumbosacral pseudoarthrosis is a common complication following adult spine deformity (ASD) surgery. This study assessed the reoperation rate for L5-S1 pseudoarthrosis in the ASD population. Compared with transforaminal lumbar interbody fusions (TLIFs), we hypothesized that anterior lumbar interbody fusion (ALIF) would result in lower rates of L5-S1 pseudarthrosis. This is a single center study with patient data retrieved from a prospective ASD database. The patients had a long-segment fusion, ALIF or TLIF at the L5-S1 level with a 2-year follow-up and were divided into 2 groups (TLIF and ALIF). The study's primary outcome was to assess the difference in the reoperation rate for clinical pseudoarthrosis between the TLIF and the ALIF groups. The secondary outcomes measured the radiological pseudoarthrosis rate and identified risks for L5-S1 pseudoarthrosis development. A total of 100 patients were included; 49 patients (mean age, 62.9 years; 77.5% females) were in TLIF and 51 patients (mean age, 64.4 years; 70.6% females) were in the ALIF group. Baseline characteristics were similar in both groups. Thirteen (13%) patients with L5-S1 pseudoarthrosis required reoperation. Clinical pseudoarthrosis was higher in the TLIF group than in the ALIF group (12/49 vs. 1/51; P < 0.001). Univariate analysis demonstrated a higher risk of L5-S1 pseudoarthrosis with TLIF than ALIF (risk ratio, 12.4; 95% confidence interval: 1.68–92.4; P < 0.001). Multivariate analysis revealed 4.86 times the risk of L5-S1 clinical pseudoarthrosis with TLIF than with ALIF (risk ratio, 4.86; 95% confidence interval 0.57–47; P = 0.17), but this ratio did not reach statistical significance. No difference in reoperation risk for L5-S1 pseudarthrosis was observed based on the method of IF. rhBMP-2 was noted as a significant predictor. [ABSTRACT FROM AUTHOR]

To establish minimum clinically important difference (MCID) in anterior lumbar interbody fusion (ALIF) for the physical function patient-reported outcome measures, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form (SF-12) physical component score (PCS), Veterans RAND 12 (VR-12) PCS, and pain patient-reported outcome measures visual analog scale (VAS) back and VAS leg through anchor- and distribution-based calculations. Patients undergoing ALIF with preoperative and 6-month Oswestry Disability Index were included. Using Oswestry Disability Index as the anchor, anchor-based calculation methods were the average change, minimum detectable change, and receiver operating characteristic curve methods. Distribution-based methods were the standard error of measurement, reliable change index, effect size, and half of the standard deviation (0.5ΔSD). Fifty-one patients were identified. Anchor-based methods ranged from 2.9 to 11.5 for PROMIS-PF, 8.2–13.6 for SF-12 PCS, 7.8–16.8 for VR-12 PCS, 0.5–3.9 for VAS back, and 1.0–3.4 for VAS leg. The area under curve ranged from 0.59 (VAS back) to 0.78 (VR-12 PCS). Distribution-based methods ranged from 1.0 to 4.2 for PROMIS-PF, 1.8–12.2 for SF-12 PCS, 1.9–6.2 for VR-12 PCS, 0.4–1.6 for VAS back, and 0.5–1.7 for VAS leg. The MCID values greatly relied on the calculation method. The minimum detectable change method was selected as the most appropriate MCID calculation method. The MCID values that may be utilized for ALIF patients are 7.3 for PROMIS-PF, 8.2 for SF-12 PCS, 7.8 for VR-12 PCS, 3.2 for VAS back, and 2.2 for VAS leg. [ABSTRACT FROM AUTHOR]