Does Anterior Lumbar Interbody Fusion Reduce Mechanical Complication and Pseudarthrosis Rate at the Lumbosacral Junction in Adult Spinal Deformity Surgery in Comparison to Posterior Lumbar Interbody Fusion?

Mohamed Kamal A. Mohamed; Michael Rauschmann; Andrei Slavici; Marcus Rickert; Sebastian Walter; Nikolaus Kernich; Krishnan Sircar; Peer Eysel; Vincent J. Heck

doi:10.14444/8774

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Figure 1
Radiographs of a 76-year-old woman with degenerative lumbar scoliosis. She underwent primary T10-pelvic fixation with posterior lumbar interbody fusion at L2–L3, L3–L4, and L4–L5 and ALIF at L5–S1 using a 4-web titanium cage in the same setting. (A) Preoperative radiograph. (B) Postoperative radiographs show a good reconstruction of the coronal alignment and spinopelvic parameters at a 2-year follow-up. (C) Computed tomography scan confirmed solid bridging fusion at the lumbosacral junction.
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Figure 2
Radiographs of an 80-year-old woman with degenerative lumbar scoliosis. In the same setting, she underwent primary T10-pelvic fixation with posterior lumbar interbody fusion at L1–L2, L2–L3, L3–4, and L4–L5 and PLIF at L5–S1. (A) Preoperative radiograph. (B) Postoperative radiographs show sufficient reconstruction of the coronal alignment and spinopelvic parameters. (C) A follow-up radiograph performed to investigate sudden low back pain 19 mo after surgery revealed rod breakage. (D) The computed tomography scan showed L5/S1 pseudarthrosis, confirmed by intraoperative findings. The performed posterior laminectomy to address the initially severe spinal canal and neuroforaminal stenosis is clearly visible.
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Figure 3
Comparison of the Mechanical Complications Rate between the 2 Groups.
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Figure 4
ROC Curve of the Anterior Lumbar Interbody Fusion Technique for Mechanical Complications Rate.

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Table 1

Patients’ Demographics and Baseline Characteristics.

Variable	ALIF (n = 32)	PLIF (n = 24)	P
Age, y	80.5 ± 5.5	78 ± 7.8	0.182
Gender, woman	28 (87.5%)	21 (87.5%)	>0.999
BMI	27 ± 3.6	28.1 ± 3.7	0.261
ASA classification
2	15 (46.9%)	8 (33.3%)	0.313
3	17 (53.1%)	16 (66.7%)	0.313
Preoperative Cobb angle	29.3 ± 7.97	29.4 ± 8.6	0.985

Abbreviations: ALIF, anterior lumbar interbody fusion; ASA, American Society of Anesthesiologists; BMI, body mass index; PLIF, posterior lumbar interbody fusion.
Note: Data presented as mean ± SD or n (%).

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Table 2

Comparison of Perioperative Parameters between the 2 Groups.

Variable	ALIF (n = 24)	PLIF (n = 24)	P
Total operative time, min	442.5 ± 107.6	391.8 ± 87.8	0.065
Blood loss, mL	2734 ± 656	4191 ± 2073	<0.001
Blood transfusion, RBC units	2.3 ± 1.2	3.2 ± 1.7	0.03
Postoperative ICU stay, d	1.2 ± 0.4	2.1 ± 1.5	0.004
Length of hospital stay, d	11.1 ± 3.3	16.9 ± 5.7	<0.001
Upper instrumented vertebrae
T3	0 (0%)	1 (4.2%)	0.595
T6	1 (3.1%)	0 (0%)
T8	3 (9.4%)	2 (8.3%)
T9	3 (9.4%)	1 (4.2%)
T10	23 (71.9%)	16 (66.7%)
T11	2 (6.2%)	3 (12.5%)
T12	0 (0%)	1 (4.2%)

Abbreviations: ALIF, anterior lumbar interbody fusion; ICU, intensive care unit; PLIF, posterior lumbar interbody fusion; RBC, red blood cell.
Note: Data presented as mean ± SD or n (%).

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Table 3

Comparison of Postoperative Outcome and Mechanical Complications between the 2 Groups.

Variable	ALIF (n = 32)	PLIF (n = 24)	P
Overall mechanical complications rate	2 (6.2%)	9 (37.5%)	0.003
Type of mechanical complications
Screw loosening	0 (0%)	4 (16.7%)	0.0646
Screw breakage	0 (0%)	1 (4.2%)
Rod breakage	1 (3.1%)	2 (8.3%)
Rod dislocation	0 (0%)	1 (4.2%)
Sacrum fracture	1 (3.1%)	1 (4.2%)
Implant-related pain	0 (0%)	4 (16.7%)	0.017
Pseudarthrosis rate	1 (3.1%)	5 (20.8%)	0.035
Reoperation	1 (3.1%)	5 (20.8%)	0.035

Abbreviations: ALIF, anterior lumbar interbody fusion; PLIF, posterior lumbar interbody fusion.

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Table 4

Logistic Regression Analysis of Factors associated with Mechanical Complications in relation to the Surgical Approach (ALIF vs PLIF).

Step 1^a	B	P	Exp(B)	95% CI for EXP(B)
Step 1^a	B	P	Exp(B)	Lower	Upper
Blood loss (mL)	0.001	0.594	1.001	0.998	1.004
Blood transfusion (RBC units)	–0.085	0.936	0.919	0.116	7.298
Total operative time (min)	–0.048	0.026	0.914	0.854	0.994
Hospital stay (d)	1.074	0.008	2.926	1.328	6.444
Pseudarthrosis rate	1.252	0.026	1.970	1.131	2.620
Postoperative ICU stay (d)	1.438	0.249	0.421	0.366	48.494
Constant	–2.826	0.665	0.059

Abbreviations: ALIF, anterior lumbar interbody fusion; ICU, intensive care unit; PLIF, posterior lumbar interbody fusion; RBC, red blood cell.
Note: "Step 1a" means that this is the first model of the stepwise logistic regression, and the variables listed here were evaluated in that model. Exp(B) represents the odds ratio. Variables significantly associated with mechanical complications in the model were hospital stay, total operative time, and pseudarthrosis rate.