Neurological Complications Following Anterior Lumbar Interbody Fusion (ALIF): A Systematic Review

Study Design Systematic review.Objective To investigate the incidence and risk factors of neurological complications following anterior lumbar interbody fusion (ALIF) for minimizing their occurrence.Methods A comprehensive literature search was conducted to identify articles reporting neurological complications following an ALIF. Studies evaluating outcomes following a lateral antepsoas or transpsoas approach, abstracts without full text available, and non-English manuscripts were excluded. For outcome measures, we collected information on the type of neurological complications and their incidence.Results A total of 16 articles met the final inclusion criteria. The overall rate of neurological complications following an ALIF ranged from 4.1% to 7.7%, While the rates of nerve root injury/lumbar plexus injury in patients undergoing surgery for degenerative pathology were less than 4%, the rates were notably higher in patients undergoing an ALIF at L5-S1 and those with spinal deformity (up to 38.4%). The risk for retrograde ejaculation (RE, due to sympathetic nerve injury) was 0.1-3.2% with a retroperitoneal approach. Reported risk factors for neurological complications included the subluxation of the superior articular facet and excessive traction by the ALIF interbody for nerve root injury, transperitoneal approach, aggressive traction on the plexus, electrocautery use, and the application of recombinant human bone morphogenetic protein. However, technical pearls to avoid neurological complications remain controversial.Conclusions Several neurologic complications have been reported following ALIF procedures across various pathologies. To mitigate the neurological complications following ALIF, careful preoperative surgical planning and meticulous attention to disc space distraction as well as manipulation of critical structures are essential.