Single-Level ALIF/LLIF and TLIF are Associated with Identical Rates of All-Cause Subsequent Lumbar Surgery

Introduction: Anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), and transforaminal lumbar interbody fusion (TLIF) are widely used for degenerative disc disease. Lumbar fusions have high rates of reoperation primarily related to adjacent segment pathology and pseudarthrosis. This study compares reoperation rates and complications following single-level ALIF/LLIF and TLIF with same-day posterior instrumentation.

Methods: The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF with posterior instrumentation. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms prior to surgery. The two cohorts, ALIF/LLIF and TLIF, were matched 1:1 based on age, sex, ECI, smoking, and diabetes. The primary outcome was all-cause subsequent lumbar surgery. Secondary outcomes included 90-day surgical complications. Categorical variables were compared with Chi-squared tests, and continuous variables with t-tests.

Results: A total of 62,291 patients met inclusion and exclusion criteria (n=14,673 ALIF/LLIF; n=47,618 TLIF). After 1:1 matching, each cohort contained 14,070 patients. Mean follow-up was 5.92 (±2.62) years. All-cause subsequent surgery was identical at 5-year follow-up (13.8%, p=1). When categorized by specific procedure, 1-year follow-up revealed TLIF had more exploration of fusions (0.7% vs. 1%, p=0.02). 5-year follow-up revealed TLIF had more arthrodesis procedures (6.5% vs. 7.3%, p =0.03) and reinsertion of fixation devices (1.3% vs. 1.7%, p =0.02), while ALIF/LLIF had more removals of instrumentation (3.1% vs. 2.5%, p =0.002). Within 90 days, TLIF had more infections (1.3% vs. 1.7%, p=0.007) and dural injuries (0.2% vs. 0.4%, p=0.001). There was no difference in wound dehiscence, hardware complications, or medical complications.

Conclusion : As utilized in real-world clinical practice, anterior versus posterior approach for interbody fusion has no effect on long term reoperation rates. TLIF patients faced a higher risk of infection and dural injury.