Original ArticleSingle-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion versus Anterior Lumbar Interbody Fusion with Posterior Instrumentation at L5/S1
Introduction
Degenerative disc and facet joint disease of the lumbar spine is a leading cause of disability in the elderly population, and, when symptomatic, results in mechanical back pain, radicular symptoms, and reduced mobility.1 When initial conservative management of lumbar spondylosis fails, surgical interbody fusion to stabilize the vertebral segment is an effective treatment modality that provides restoration of lordosis, neural decompression, and correction of deformity.1, 2, 3 The 2 predominant techniques used for arthrodesis at lumbar level L5/S1 are anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF). Each technique has its own associated approach-specific advantages and drawbacks, and radiographic studies comparing the 2 approaches have shown no significant differences in rates of fusion.4 In addition, the literature comparing the 2 techniques has predominantly emphasized differences in complication rates and radiographic parameters, with little focus on patient-perceived clinical outcomes.1,4, 5, 6
To show value in spinal surgery, increased attention has been placed on metrics called patient-reported outcome measures (PROMs), which provide surgeons with insight into patient perceptions of their health status.7, 8, 9, 10 PROMs commonly used in lumbar spine surgery include the visual analog scale (VAS) back and leg measures for pain, Oswestry Disability Index (ODI), 12-Item Short-Form (SF-12) Physical Component Summary (PCS) and Mental Component Summary, and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF).7, 8, 9, 10
As reported in the systematic review by Schroeder et al.,11 previous studies comparing radiographic parameters and complication rates between ALIF and TLIF are abundant; however, studies comparing the 2 techniques with adequate power and long-term clinical follow-up via PROMs are scarce. Furthermore, because both techniques are increasingly being performed in an outpatient setting via ambulatory surgery centers, level-specific information tying techniques to clinical outcomes has become increasingly important for surgeons and hospital administrators alike.
To optimize surgical outcomes, it is necessary to curate surgical approaches based on the anatomy and preoperative characteristics of patients. Given the high prevalence of lumbar degenerative disease at the L5/S1 level, the transition toward performing more spinal surgery in an outpatient setting and inconclusive clinical comparisons between techniques, further investigation is required regarding the comparative clinical outcomes of minimally invasive surgery (MIS) TLIF and ALIF procedures at this level.12, 13, 14
To address this gap in the literature, our study compared patient-reported outcomes, perioperative outcomes, recovery ratios (RRs), and postoperative complications between MIS-TLIF and ALIF at the L5-S1 level for a large patient cohort, providing surgeons with direction regarding level-specific spinal fusion management.
Section snippets
Patient Population
The institutional review board (ORA number 14051301) approved all aspects of the current study and all participants provided written informed consent before commencement. Eligible study participants were identified via a retrospective review of a prospective single-surgeon database for spinal procedures performed at a single academic medical institution. Inclusion criteria permitted the study of patients who underwent primary, elective, single-level TLIF and ALIF procedures. Any patient who had
Descriptive Analysis
Before coarsened exact matching, 405 patients met the inclusion criteria: 346 in the MIS-TLIF cohort and 59 in the ALIF cohort (Table 1). The patient cohort before match significantly differed for all preoperative presenting spinal disease (P < 0.009, all) as well as on the basis of age and insurance status (P < 0.004, all) (Tables 1 and 3). After coarsened exact match, 262 patients were removed from the study and the final patient cohort consisted of 143 patients: 93 in the MIS-TLIF cohort and
Discussion
The predominant approaches for fusion at L5/S1 are TLIF and ALIF, with both techniques showing efficacy in achievement of lumbar arthrodesis and improvement of patient signs and symptoms associated with lumbar spondylolysis.2,3,7,9,12,14 First described by Capener in 1932, ALIF provides direct anterior access to the lumbar disc space via a muscle-splitting retroperitoneal approach, allowing for less disruption of the posterior spinal elements, with the most-cited approach-specific complications
Conclusions
For patients undergoing single-level fusion at L5/S1, those who underwent ALIF showed significantly greater operative times and estimated blood loss, significantly reduced postoperative narcotic consumption on day of surgery and significantly improved SF-12 PCS at 6 weeks and 1 year, ODI at 6 weeks, VAS back at 6 weeks, and PROMIS-PF at 6 weeks versus patients undergoing MIS-TLIF. In addition, a significantly greater percentage of patients in the ALIF cohort achieved MCID at the 6-week time
CRediT authorship contribution statement
Kevin C. Jacob: Conceptualization, Methodology, Writing – original draft, Writing – review & editing, Visualization, Formal analysis, Software, Investigation. Madhav R. Patel: Conceptualization, Methodology, Writing – original draft, Writing – review & editing, Visualization, Formal analysis, Software, Investigation. Max A. Ribot: Writing – original draft, Project administration, Data curation, Investigation, Writing – review & editing. Alexander W. Parsons: Writing – original draft, Project
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.