Review article
A meta-analysis comparing ALIF, PLIF, TLIF and LLIF

https://doi.org/10.1016/j.jocn.2017.06.013Get rights and content

Highlights

  • ALIF, PLIF, TLIF and LLIF had similar fusion rates.

  • ALIF achieved better postoperative disc height and postoperative segmental lordosis.

  • TLIF had better Oswestry Disability Index (ODI) scores.

  • PLIF had the greatest blood loss.

  • Complication rates were similar across approaches.

Abstract

Introduction

Lumbar interbody fusions have been widely used to treat degenerative lumbar disease that fails to respond to conservative treatment. This procedure is divided according to its approach: anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF). Each approach has its own theoretical advantages and disadvantages; however, there have been no studies that compared these.

Methods

Various full-text databases were systematically searched through December 2015. Data regarding the radiological, operative and clinical outcomes of each lumbar interbody fusion were extracted. All outcomes were pooled using random effects meta-analysis, with the relative risk (RR) and/or weighted mean difference (WMD) as the summary statistic.

Results

Thirty studies met the inclusion criteria. The ALIF procedure has been studied most intensively, followed by PLIF, TLIF and LLIF respectively. All four approaches had similar fusion rates (p = 0.320 & 0.703). ALIF has superior radiological outcome, achieving better postoperative disc height (p = 0.002 & 0.005) and postoperative segmental lordosis (p = 0.013 & 0.000). TLIF had better Oswestry Disability Index scores (p = 0.025 & 0.000) while PLIF had the greatest blood loss (p = 0.032 & 0.006). Complication rates were similar between approaches. Other comparisons were either inconclusive or lacked data. There was marked less studies comparing against LLIF.

Conclusions

Each approach has their own risks and benefits but similar fusion rates. Despite the large number of studies, there is little data overall when comparing specific aspects of lumbar interbody fusions. More studies, especially RCTs are needed to further explore this topic.

Introduction

Non-specific lower back pain caused by degenerative lumbar disease such as disc and facet joint degeneration or spondylolisthesis significantly impairs quality of life of patients, and is associated with higher pain scores and reduced function. Patients that fail to respond to conservative treatment may require surgical intervention, such as lumbar interbody fusion (LIF) [1]. This procedure is divided into several types depending on its approach, which are anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) [2]. These procedures involve a bone graft between the vertebrae to unite the bones of opposing vertebral endplates adjacent to the degenerative disc, and may also include other instrumentation, such as pedicle screws, plates or cages for structural integrity.

In US, the rates of spinal fusion procedures in patients with non-specific back pain are on the rise [3]. Each surgical approach has both benefits and limitations. For example, ALIF uses a retroperitoneal approach to expose the anterior spine, and is therefore associated with increased risk of direct vascular injury and ureteral injury [4], [5]. However, by avoiding dissection of paraspinal muscles, ALIF patients have reduced postoperative pain and shorter inpatient stays [6], [7], [8] On the other hand, PLIF accesses disc space via a direct posterior approach through a midline incision. This is beneficial in avoiding approach-related vascular complications associated with ALIF, and it also allows for better surgical exposure for decompression of the neural elements [9]. The posterior approach is however associated with neurological complications due to risk of retraction on thecal sac and nerve roots, with reported rates of 9.0–24.6% postoperative neurological deficit [10].

With regards to TLIF, its transforaminal approach avoids significant vascular complications, and has a lower rate of neurological complications when compared to PLIF. The disadvantages of TLIF are its extensive muscle retraction and dissection, which may lead to postoperative pain, delayed rehabilitation and impaired spinal function [11]. In contrast, LLIF takes on a lateral incision to access the retroperitoneal space to allow discectomy and end plate preparation. The trans-poas approach is beneficial in that it avoids manipulation of aorta or vena cava, avoids neurological injury as well as spares the paraspinal muscles [12]. Despite the benefits, LLIF involves the splitting of psoas muscle, which may incur damage to neural structures such as the lumbar plexus, causing lower limb weakness and paraesthesias [13], [14].

Despite the knowledge about each individual approach, there have not been any studies that compared the outcomes of these four different approaches. Thus, this study aims to compare the radiological, operative and clinical outcomes of the ALIF, PLIF, TLIF and LLIF in treating degenerative lumbar spinal disease through a meta-analysis.

Section snippets

Methods

Recommended guidelines for systematic review and meta-analyses were followed [15].

Literature search

The electronic searches identified 6114 articles, of which 40 full texts were assessed for eligibility. Thirty studies met the criteria for inclusion in the meta-analysis (Fig. 1). Table 1 shows the main characteristics of included studies. There were 5 studies that compared ALIF with PLIF, 7 studies that compared PLIF with TLIF, 9 studies that compared ALIF with TLIF, 3 that compared ALIF with LLIF, 3 that compared TLIF with LLIF, 1 that compared PLIF with LLIF, 1 that compared ALIF, PLIF and

Discussion

The ALIF procedure has been studied most intensively, followed by PLIF, TLIF and LLIF respectively. Our study shows that ALIF, PLIF and TLIF have similar fusion rates, which is not an unexpected finding as fusion is generally dependent on patient selection, endplate preparation and choice of graft material [16], [17]. It is outside the scope of this meta-analysis however, to compare interbody technique versus graft choice and fusion rates. Placement of the graft within the load-bearing column

Disclosure

This paper does not receive any funding from any parties.

Conflicts of interests

None.

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