ALIF Versus TLIF for L5-S1 Isthmic Spondylolisthesis: ALIF Demonstrates Superior Segmental and Regional Radiographic Outcomes and Clinical Improvements Across More Patient-reported Outcome Measures Domains

Lightsey, Harry M.; Pisano, Alfred J.; Striano, Brendan M; Crawford, Alexander M; Xiong, Grace; Hershman, Stuart H.; Schoenfeld, Andrew J.; Simpson, Andrew K.

doi:10.1097/brs.0000000000004333

Cited by 27 publications

(21 citation statements)

References 29 publications

(64 reference statements)

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“…13 A separate study by Kim et al 12 Previous literature has illustrated that ALIF demonstrates superior segmental and regional lordosis correction compared with TLIF. [23][24][25] Greater lordotic correction may allow for decreased rates of adjacent segment degeneration among TLIF patients, as reported by Lee et al 26 Of note, our PROM scores and MCID achievement rates were equal in the past 12 weeks, suggesting that improvements in lordosis from ALIF may not necessarily implicate superior improvements in quality-of-life outcomes. This concept is closely related to statements by Horsting et al, 27 which note that radiographic adjacent segment disease may not influence clinical outcome scores.…”

Section: Discussionsupporting

confidence: 66%

Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody Fusion for the Surgical Treatment of Isthmic Spondylolisthesis

Patel

Jacob

Pawlowski

et al. 2022

J Am Acad Orthop Surg

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Introduction:Limited studies have compared minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) with anterior lumbar interbody fusion (ALIF) for the treatment of isthmic spondylolisthesis. This study aims to compare perioperative variables, patient-reported outcome measures (PROMs), and minimal clinically important difference (MCID) achievement rates between these surgical approaches.Methods:Patients with isthmic spondylolisthesis undergoing primary, single-level MIS TLIF or ALIF were identified in a surgical database. Patients were divided into MIS TLIF and ALIF cohorts. Demographics and perioperative characteristics were collected and compared between groups using the chi square test or Student t-test. PROMs including the Patient-Reported Outcomes Measurement Information System Physical Function, 12-Item Short Form Physical Composite Score, visual analog scale (VAS) back, VAS leg, and Oswestry Disability Index were collected at preoperative, 6-, 12-week, 6-month, 1-, and 2-year time points. Mean PROMs were compared using the Student t-test for independent samples. MCID attainment was determined using established values in the literature; achievement rates by grouping were compared using chi square analysis.Results:One hundred seventy-one patients were included, 121 MIS TLIF and 50 ALIF. No demographic differences were observed. Mean surgical times were 139.7 minutes (MIS TLIF) and 165.5 minutes (ALIF) (P < 0.001). No other perioperative differences were observed. Mean estimated blood loss values were 63.8 mL (MIS TLIF) and 73.7 mL (ALIF). Mean postoperative lengths of stay were 43.9 hours (MIS TLIF) and 42.5 hours (ALIF). Mean PROMs did not markedly differ among groups at any time point. MCID attainment was markedly higher among MIS TLIF patients for the Oswestry Disability Index at 6 weeks (P = 0.046) and 12 weeks (P = 0.007), Patient-Reported Outcomes Measurement Information System Physical Function at 12 weeks (P = 0.015), and VAS leg at 6 weeks (P = 0.031) and 12 weeks (P = 0.045). No other notable differences were observed among MCID achievement by grouping.Discussion:While single-level ALIF demonstrated markedly higher surgical times, other perioperative characteristics and PROMs were comparable among ALIF and MIS TLIF patients. Although MCID achievement rates were generally lower for disability and leg pain among ALIF patients, significance was not reached at 6 months, 1 year, or during the overall postoperative period after fusion.

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Section: Discussionsupporting

confidence: 66%

Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody Fusion for the Surgical Treatment of Isthmic Spondylolisthesis

Patel

Jacob

Pawlowski

et al. 2022

J Am Acad Orthop Surg

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Section: Discussioncontrasting

confidence: 57%

“…Previous studies have found a greater generation of segmental lordosis and disc height for ALIF procedures compared to TLIF procedures, however, the biomechanical benefit associated with ALIF does not necessarily translate to improvement in PROs. 29,30 In fact, our findings suggest that ID may even be associated with worse short-term pain evidenced by less improvement of leg pain and back pain in the early postoperative period at 3 months. Whether this was due to residual leg pain from inadequate decompression or thigh pain from the transpsoas approach is unclear, and overall, the differences normalized at 12 months and both groups achieved good outcomes.…”

Section: Discussionmentioning

confidence: 65%

“…Whether this was due to residual leg pain from inadequate decompression or thigh pain from the transpsoas approach is unclear, and overall, the differences normalized at 12 months and both groups achieved good outcomes 31. This is in contrast with Lightsey et al ,30 who found ALIF patients had significant improvement in Physical Function and Global Health—Physical scores while TLIF patients did not. While Lightsey and colleagues focused solely on patients who received a single level interbody fusion at L5–S1, our study included both single and multilevel fusions, which may explain the differing results.…”

Section: Discussionmentioning

confidence: 85%

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Outcomes Following Direct Versus Indirect Decompression Techniques for Lumbar Spondylolisthesis

McKeithan

Romano

Waddell

et al. 2022

Spine

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Study Design. Retrospective review. Objective. The aim was to compare outcomes at 3 and 12 months for patients with lumbar spondylolisthesis treated with direct decompression (DD) versus indirect decompression (ID) techniques. Summary of Background Data. Debate persists regarding the optimal surgical strategy to treat lumbar spondylolisthesis. Novel techniques relying on ID have shown superior radiographic outcomes compared to DD, however, doubt remains regarding their effectiveness in achieving adequate decompression. Currently, there is a paucity of data comparing the clinical efficacy of DD to ID. Methods. The Quality Outcomes Database (QOD), a national, multicenter prospective spine registry, was queried for patients who underwent DD and ID between April 2013 and January 2019. Propensity scores for each treatment were estimated using logistic regression dependent on baseline covariates potentially associated with outcomes. The propensity scores were used to exclude nonsimilar patients. Multivariable regression analysis was performed with the treatment and covariate as independent variables and outcomes as dependent variables. Results. A total of 4163 patients were included in the DD group and 86 in the ID group. The ID group had significantly lower odds of having a longer hospital stay and for achieving 30% improvement in back and leg pain at 3 months. These trends were not statistically significant at 12 months. There were no differences in ED5D scores or Oswestry disability index 30% improvement scores at 3 or 12 months. ID patient had a significantly higher rate of undergoing a repeat operation at 3 months (4.9% vs. 1.5%, P=0.015). Conclusion. Our study suggests that both DD and ID for the treatment of lumbar spondylolisthesis result in similar clinical outcomes, with the exception that those treated with ID experienced a lower reduction in back and leg pain at 3 months and a higher 3-month reoperation rate. This data can provide surgeons with additional information when counseling patients on the pros and cons of ID versus DD surgery.

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“…Aggregating the multitude of data and deciding on a specific procedural plan is rather complex and often a group of spine surgeons will arrive at differing solutions to a similar clinical presentation. 24,25 While there may be any number of acceptable procedural solutions for a given patient with a specific pathology which will result in clinical improvement, there is likely a single optimal or ideal solution. In the future, with broader availability of data around patient clinical and anatomic factors, as well as outcome data, it is likely that spine physicians will have access to data-driven decision aids integrated into electronic health platforms.…”

Section: Data and Decision Aidsmentioning

confidence: 99%

The Future of Spine Care Innovation - Software not Hardware: How The Digital Transformation Will Change Spine Care Delivery

Simpson

Crawford

Striano

et al. 2022

Spine

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Study Design. Narrative review.Objective. The aim was to utilize the lessons from the digital transformation of industries beyond healthcare, weigh the changing forces within the healthcare ecosystem, and provide a framework for the likely state of spine care delivery in the future. Summary of Background Data. Advances in technology have transformed the way in which we as consumers interact with most products and services, driven by devices, platforms, and a dramatic increase in the availability of digital data. Spine care delivery, and much of healthcare in general, has lagged far behind, hamstrung by regulatory limitations, narrow data networks, limited digital platforms, and cultural attachment to legacy care delivery models. Methods. The authors present a narrative review of the current state of the spine field in this dynamic and evolving environment. Results. The past several decades of spine innovation have largely been driven by "hardware" improvements, such as instrumentation, devices, and enabling technologies to facilitate procedures. These changes, while numerous, have largely resulted in modest incremental improvements in clinical outcomes. The next phase of growth in spine care, however, is likely to be more reflective of the broader innovation ecosystem that has already transformed most other industries, characterized by improvements in "software," including: (1) leveraging data analytics with growing electronic health records databases to optimize interactions between patients and providers, (2) expanding digital and telemedicine platforms to create integrated hybrid service lines, (3) data modeling for patient and provider decision aids, (4) deploying provider and service line performance metrics to improve quality, and (5) movement toward more free market dynamics as patients increasingly move beyond legacy limited health system networks. Conclusion. Spine care stakeholders should familiarize themselves with the concepts discussed in this review, as they create value for patients and are also likely to dramatically shift the spine care delivery landscape.

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ALIF Versus TLIF for L5-S1 Isthmic Spondylolisthesis: ALIF Demonstrates Superior Segmental and Regional Radiographic Outcomes and Clinical Improvements Across More Patient-reported Outcome Measures Domains

Cited by 27 publications

References 29 publications

Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody Fusion for the Surgical Treatment of Isthmic Spondylolisthesis

Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody Fusion for the Surgical Treatment of Isthmic Spondylolisthesis

Outcomes Following Direct Versus Indirect Decompression Techniques for Lumbar Spondylolisthesis

The Future of Spine Care Innovation - Software not Hardware: How The Digital Transformation Will Change Spine Care Delivery

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