Anterior Lumbar Interbody Fusion (ALIF) L5-S1 with overpowering of posterior lumbosacral instrumentation and fusion mass: a reliable solution in revision spine surgery

Abstract

Background and purposeIn cases of spine surgical revisions of patients affected by sagittal malalignment, the restoration of the ideal lumbar lordosis (LL) is mandatory. ALIF procedures represent a powerful and effective approach to improve the LL in case of hypolordosis. This study evaluates the feasibility of ALIF to overpower posterior lumbar instrumentation and fusion mass in revision spine surgery and secondarily to estimate complications, clinical and radiological outcomes. Methods This is a single-center retrospective analysis of prospectively collected data on the use of ALIF overpowering in cases of lumbosacral instrumentation and/or fusion. Demographic, comorbidity, corrective strategy adopted, surgical data, clinical and radiological results, and intraoperative and postoperative complications were recorded. Results Twelve patients (3 male; 9 female) underwent overpowering ALIF L5-S1 were included in the study with a mean FU of 34.0 ± 13.4 months. In 10 cases, a posterior titanium instrumentation and fusion mass were present; in 2 patients, only a fusion mass was present. Indicators of pain and disability improved in all patients (p < 0.01). Sagittal realignment with the restoration of ideal spinopelvic parameters was obtained in all cases. One peritoneal lesion requiring intraoperative suture without sequelae, two cases of postoperative radiculopathy, and one posterior wound infection requiring surgical debridement and antibiotic therapy were reported. Conclusions Anterior implant of lordotic and hyperlordotic cages with increasing segmental lordosis is possible in the presence of posterior instrumentation and/or solid fusion mass. The biomechanical strength of this corrective technique can overcome posterior instrumentation and bone fusion resistance, therefore allowing a single-staged surgery for sagittal realignment.

Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case

“… 4 , 6 , 9 , 10 From a technical perspective, LALIF offers all the benefits of an anterior approach to the spine, even in the presence of posterior instrumentation. 1 , 2 , 4 , 5 , 14 , 15 , 18 …”

“…The LALIF technique can provide a safe passage by avoiding scar tissue from prior posterior surgery and potential complications associated with revision spine surgery via a posterior approach. 1 Although combined ALIF and LLIF have been described in supine position, it may still require turning the patient to the prone position for posterior instrumentation to achieve a circumferential fusion. 19 LALIF increases operating room efficiency by facilitating single-position surgery, especially when fusion at multiple lumbar levels is required.…”

“… 1 , 4 , 13 , 15 , 16 , 18 , 20 Specific attention needs to be paid to the vascular anatomy, particularly the sacral veins, which may need to be ligated and divided as has been well described. 1 , 11 , 12 , 16 , 20 At first, surgeons may not be familiar with performing ALIF in the lateral position, but for vascular and neurosurgeons, who work frequently as a team, these challenges can be overcome, providing LALIF as a safe, effective, and potentially advantageous alternative to standard ALIF surgery in appropriate cases. 6 , 15 , 16 , 19 …”

“… 1 An anterior approach to the spine in the form of anterior lumbar interbody fusion (ALIF) is an effective, safe, and widely used tool for segmental lordosis correction and indirect decompression. 1–3 Its advantages include access via a virgin corridor in case of previous posterior spine surgery, the ability to resect the anterior longitudinal ligament to restore lordosis, and the insertion of a large-footprint interbody cage to promote fusion, especially in the setting of prior pseudoarthrosis. 1 , 2 , 4 , 5 …”

“… 1–3 Its advantages include access via a virgin corridor in case of previous posterior spine surgery, the ability to resect the anterior longitudinal ligament to restore lordosis, and the insertion of a large-footprint interbody cage to promote fusion, especially in the setting of prior pseudoarthrosis. 1 , 2 , 4 , 5 …”