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.

UNASSIGNED: Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined.
UNASSIGNED: To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis.
UNASSIGNED: A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: \"lumbar\" and \"fractional curve\"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared.
UNASSIGNED: Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment.
UNASSIGNED: Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.

•Key anterior approaches differences in LSTV include vascular (aortic bifurcation/iliocaval confluence), muscular (psoas) and osseus anatomy (inter-crestal tangent/pubic symphysis), when compared to non-LSTV.•There are increased surgical deviations but not significantly greater complications for anterior approaches in LSTV.•Vascular awareness while accessing L45 will be in the presence of a more cephalad ABF and ICC with sacralized L5, and access to the deeper L56 level will be in the presence of a more caudal ABF and ICC in lumbarized S1.

One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review.
This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a \"safe corridor\" to avoid any potential vascular laceration.
The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation.
Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF.
A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported.
A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2-4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01-1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01-1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05-3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility.
After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

The present systematic review and pooled analysis aims to assess the incidence and risk factors for the development of retrograde ejaculation (RE) following first-time open anterior lumbar surgery.
A systematic MEDLINE review via PubMed was performed, identifying 130 clinical papers relating to the topic. Eighteen publications were selected according to predetermined inclusion and exclusion criteria and were used to determine the incidence of RE. Only the publications that provided data on surgical risk factors present specifically in the men in the study were included in the analysis of risk factors.
Of the 2503 men included, there were 57 reported events of RE (2.3%). Of the cases for which long-term data were provided, 45.8% had resolved by final follow-up. There was a statistically significant increased risk associated with a transperitoneal as opposed to a retroperitoneal approach (8.6% vs 3.2%), as well as with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) as opposed to ALIF with bone graft or arthroplasty in controls (5.0% vs 1.8%). However, when excluding from analysis the patients operated on prior to the FDA\'s 2008 warning that commented on the drug\'s neuroinflammatory properties, there was no significant difference in rates of RE in patients receiving rhBMP-2 versus the control group (2.4% vs 2.5%). There was no significant difference in risk based on single- versus multilevel procedure or on ALIF versus arthroplasty.
In a pooled analysis of currently published data on men undergoing first-time open anterior lumbar surgery, this study found an overall incidence of RE of 2.3%. Nearly half of these patients recovered, reporting resolution of symptoms anywhere between 3 months and 48 months. Analysis of risk factors was limited by a paucity of published literature segregating data by sex. However, there was an increased risk associated with rhBMP-2 only when including data collected prior to the FDA warning on its detrimental properties. The authors therefore posit that the risk of RE is probably overestimated in the literature, given that the vast majority of the data available were collected prior to this warning and given the subsequent implementation of precautions when handling rhBMP-2.

We aim at analysing the impact of anterior lumbar interbody fusion (ALIF) in restoring the main spinopelvic parameters, along with its potentials and limitations in correcting sagittal imbalance.
The 2009 PRISMA flow chart was used to systematically review the literature; 27 papers were eventually selected. The following spinopelvic parameters were observed: pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), segmental lumbar lordosis (LLseg) and sagittal vertical axis (SVA). Papers reporting on hyperlordotic cages (HLC) were analysed separately. The indirect decompression potential of ALIF was also assessed. The clinical outcome was obtained by collecting visual analogue scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) scores. Global fusion rate and main complications were collected.
PT, SS, LL, LLseg and SVA spinopelvic parameters all improved postoperatively by - 4.3 ± 5.2°, 3.9 ± 4.5°, 10.6 ± 12.5°, 6.7 ± 3.5° and 51.1 ± 44.8 mm, respectively. HLC were statistically more effective in restoring LL and LLseg (p < 0.05). Postoperative disc height, anterior disc height, posterior disc height and foraminal height, respectively, increased by 58.5%, 87.2%, 80.9% and 18.1%. Postoperative improvements were observed in VAS back and leg and ODI scores (p < 0.05). The global fusion rate was 94.5 ± 5.5%; the overall complication rate was 13%.
When managing sagittal imbalance, ALIF can be considered as a valid technique to achieve the correct spinopelvic parameters based on preoperative planning. This technique permits to obtain an optimal LL distribution and a solid anterior column support, with lower complications and higher fusion rates when compared to posterior osteotomies.

UNASSIGNED: Retrospective case series.
UNASSIGNED: Sacral insufficiency fracture is a rare and serious complication following lumbar spine instrumented fusion. The purpose of this study was to describe the patient characteristics, presentation, evaluation, treatment options, and outcomes for patients with sacral insufficiency fracture after short-segment lumbosacral fusion.
UNASSIGNED: Six patients from our institutional database and 16 patients from literature review were identified with a sacral insufficiency fracture after short-segment (L4-S1 or L5-S1) lumbar fusion within 1 year of surgery.
UNASSIGNED: Patients were 55% female with a mean age of 58 years and body mass index of 30 kg/m2. Osteoporosis or osteopenia was the most common comorbidity (85%). Half of patients sustained a sacral fracture after surgery from a posterior approach, while the others had anterior or anterior-posterior surgery. Mean time to fracture was 42 days with patients clinically presenting with new sacral pain (86%), radiculopathy (60%), or neurologic deficit (5%). Ultimately, 73% of patients underwent operative fixation often involving extension of the construct (75%) and fusion to the pelvis (69%). Men (P = .02) and patients with new radicular pain or neurologic deficit (P = .01) were more likely to undergo revision surgical treatment while women over 50 years of age were more likely to be treated conservatively (P = .003).
UNASSIGNED: Spine surgeons should monitor for sacral insufficiency fracture as a source of new-onset pain in the postoperative period in patients with a short segment fusion to the sacrum. The recognition of this complication should prompt an assessment of bone health and management of underlying bone fragility.

UNASSIGNED: Lumbar interbody fusion is among the most common types of spinal surgery performed. Over time, the term has evolved to encompass a number of different approaches to the intervertebral space, as well as differing implant materials. Questions remain over which approaches and materials are best for achieving fusion and restoring disc height.
UNASSIGNED: We reviewed the literature on the advantages and disadvantages of various methods and devices used to achieve and augment fusion between the disc spaces in the lumbar spine.
UNASSIGNED: Using search terms specific to lumbar interbody fusion, we searched PubMed and Google Scholar and identified 4993 articles. We excluded those that did not report clinical outcomes, involved cervical interbody devices, were animal studies, or were not in English. After exclusions, 68 articles were included for review.
UNASSIGNED: Posterior approaches have advantages, such as providing 360° support through a single incision, but can result in retraction injury and do not always restore lordosis or correct deformity. Anterior approaches allow for the largest implants and good correction of deformities but can result in vascular, urinary, psoas muscle, or lumbar plexus injury and may require a second posterior procedure to supplement fixation. Titanium cages produce improved osteointegration and fusion rates but also increase subsidence caused by the stiffness of titanium relative to bone. Polyetheretherketone (PEEK) has an elasticity closer to that of bone and shows less subsidence than titanium cages, but as an inert compound PEEK results in lower fusion rates and greater osteolysis. Combination PEEK-titanium coating has not yet achieved better results. Expandable cages were developed to increase disc height and restore lumbar lordosis, but the data on their effectiveness have been inconclusive. Three-dimensionally (3D)-printed cages have shown promise in biomechanical and animal studies at increasing fusion rates and reducing subsidence, but additive manufacturing options are still in their infancy and require more investigation.
UNASSIGNED: All of the approaches to spinal fusion have plusses and minuses that must be considered when determining which to use, and newer-technology implants, such as PEEK with titanium coating, expandable, and 3D-printed cages, have tried to improve upon the limitations of existing grafts but require further study.

The purpose of this study is to evaluate the feasibility and the safety of a new skin incision for minimally invasive anterior lumbar interbody fusion (ALIF): the perinavel incision.
Demographic and clinical data from patients who underwent ALIF with the perinavel incision were collected. Indications to surgery, preoperative symptoms, radiological data, number of treated levels, intraoperative and early postoperative complications and wound-related problems were analysed.
Ninety-seven patients underwent ALIF with this new skin incision. One hundred fifty-seven levels were treated (mean 1.7 level per patient) being L4-L5 the most frequently treated. Intraoperative complications were represented only by the venous injury with a rate of 3.09% (3 cases). Postoperative complications were all linked to skin incision issues: a case of wound dehiscence and a case of superficial infection. No case of skin necrosis occurs at 3-month follow-up.
In this paper, the perinavel skin incision was demonstrated to be as safe as traditional approaches for ALIF. Furthermore, with this incision it is possible to perform multilevel (L3-S1) ALIF, which means a good option in minimally invasive surgery as well as revision surgery. These slides can be retrieved under Electronic Supplementary Material.