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Anterior Lumbar Interbody Fusion: Indications and Techniques
Overview
Anterior approaches to the lumbar spine have been utilized to treat lumbar degenerative disc disease for over a century. The approach evolved from a transperitoneal approach to using a retroperitoneal surgical corridor. , The retroperitoneal approach became a favored approach, given the higher complications associated with direct manipulation of intra-abdominal contents when using the transperitoneal approach. An anterior lumbar interbody fusion (ALIF) provides a robust biomechanical construct afforded by large fusion surface area for graft placement and a relatively low complication rate. , The anterior interbody fusion technique has proven to be an efficacious procedure for patients with intractable back pain attributed to lumbar degenerative disc disease, lumbar spondylolisthesis, pseudoarthrosis from prior posterior instrumentation, and/or correction of sagittal plan deformities. This chapter reviews the benefits, indications, and surgical technique for performing an ALIF.
Advantages
The ALIF offers several advantages over posterior lumbar interbody approaches. , , The anterior approach provides direct access to the anterior column and disc spaces of L4–S1 while limiting extensive paraspinal muscle dissection that could be needed for a posterior approach. Limiting posterior paraspinal muscle dissection has been shown to result in decreased postoperative pain and subsequently decreased length of postoperative hospital stay. Avoiding disruption of posterior elements may also be contributing to the decreased rates of adjacent-segment degeneration found with a posterior lumbar interbody fusion (PLIF) technique. Retraction on neural structures is avoided through an anterior approach, as opposed to the PLIF, which requires some retraction of the neural structures for its technique. An ALIF can provide better correction of sagittal malalignment by restoring lumbar lordosis through placement of large lordotic grafts. Prior investigations in comparing the transforaminal lumbar interbody fusion technique with the ALIF technique have shown that the ALIF technique can be more efficacious in increasing the foraminal height, local disc angle, and lumbar lordosis. ,
Indications
Operative indications for an ALIF have increased over time. The optimal candidate has chronic low back pain contributed to discogenic back pain at lower lumbar levels (L3–S1) with loss of height, stability, and mobility of the diseased segment. , Most ALIFs are performed at the L4–5 and L5–S1 intervertebral disc levels. Degenerative spondylolisthesis often accompanies this patient population. In general, all conservative approaches have been exhausted and have failed in the patients selected for surgery. Other indications include revision surgery after a failed posterior fusion (pseudoarthroses) and for correction of sagittal deformities by restoring lumbar lordosis. ,
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