Single-Level Lumbar Spine Fusion: A Comparison of Anterior and Posterior Approaches

Abstract

This study is a retrospective review of 122 patients who underwent single-level lumbar spine fusion. The objectives were to directly compare perioperative morbidity and early results of single-level anterior interbody posterolateral intertransverse process lumbar spine fusion and to provide objective findings that may be useful in selecting surgical method. Lumbar spinal fusion is a well-recognized surgical treatment of intractable low back pain resulting from DDD or spondylolisthesis. Assessments of techniques, results, and outcomes have been published, but detailed head-to-head comparisons of anterior posterior approaches with objective operative and postoperative data are not available in the literature. A retrospective review of 122 patients who underwent either an anterior interbody or posterolateral intertransverse process (average follow-up 22 and 26 months, respectively) single-level instrumented lumbar spinal fusion was performed. Surgical, perioperative, and follow-up data were obtained directly from medical records. The findings compared included estimated blood loss, need for blood transfusion, number of units transfused, operative time, number of days in hospital, need for transitional facility care, complications, need for further surgery, radiographic fusion, and clinical results. There was significantly less blood loss, need for transfusion, amount of blood transfused, operative time, and hospital stay for patients with anterior fusion procedures (p < 0.01). There was no significant difference in need for transitional facility care, complication rates, and given follow-up period in radiographic fusion rate and clinical outcome. Clinical results were significantly worse for those undergoing revision primary fusion (p < 0.01). The anterior approach to single-level lumbar fusion is associated with less morbidity than the posterolateral approach. This may in turn affect surgical outcome and hospital cost. However, both approaches to single-level lumbar fusion produce similar early fusion rates and clinical results. Revision fusions had poor early results regardless of approach.

Impact of surgical approach on complication rates after elective spinal fusion (≥3 levels) for adult spine deformity

“…Similarly, in a retrospective study of 1,014 consecutive patients undergoing posterior lumbar fusion, Takahashi et al identified female sex, older age as well as underlying degenerative spondylolisthesis and juxtafacet cysts as risk factors for incidental durotomy (12). Given the higher risk of blood loss associated with posterior approaches by both our study and the literature (2,4,5), preoperative identification of these risk factors might sway surgical decision-making in favor of an anterior approach. Similarly, demographic variables and underlying spinal pathology influence risk of intraoperative incidental durotomy.…”

“…Anterior approaches to lumbar fusion typically involve retroperitoneal or transperitoneal approaches performed in close proximity to the ureter, peritoneum, and iliac vessels (2,5). As a result, anterior approaches often involve ligation of sacral and lumbar segmental vessels and require splitting the abdominal muscles and retracting the iliac vessels, posing a higher risk of iliac vessel or presacral plexus damage and resultant hemorrhage compared to posterior approaches (2,5). Patient characteristics and operative variables that pose a higher risk for the different complications associated with each approach should be considered.…”

“…Freudenberger et al reported similar fusion rates between anterior and posterior approaches to interbody lumbar fusion using anterior tension band plating (4). Similarly, in a comparison of anterior and posterior approaches to singlelevel lumbar fusion, Pradhan et al reported similar fusion rates and clinical results with both approaches (5). However, little remains known about the implications of different surgical approaches on surgical complications after spinal fusion, especially after fusion involving greater than three levels.…”

Anterior Lumbar Interbody Fusion with Stand-Alone Interbody Cage in Treatment of Lumbar Intervertebral Foraminal Stenosis : Comparative Study of Two Different Types of Cages

“…Recently, the improved devices to enhance a stabilization effect for single anterior surgery have been introduced and promoted the fusion rate. Current reports of open ALIF surgery have stated 93-100% of fusion success rate, which would be comparable with other fusion procedures 4,[18][19][20]25) . However, the present study showed about 84-86% of fusion success rate, which was relatively inferior to other results previously reported.…”

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: Interbody techniques for lumbar fusion

“…8 The follow-up period was 22 months for ALIF and 26 months for PLF. Fusion was assessed based on flexion-extension radiographs and CT scanning for ambiguous cases.…”