Single position lateral decubitus anterior lumbar interbody fusion (ALIF) and posterior fusion reduces complications and improves perioperative outcomes compared with traditional anterior-posterior lumbar fusion

BACKGROUND CONTEXT: Lateral decubitus single position anterior-posterior (AP) fusion utilizing anterior lumbar interbody fusion and percutaneous posterior fixation is a novel, minimally invasive surgical technique. Single position lumbar surgery (SPLS) with anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF) has been shown to be a safe, effective technique. This study directly compares perioperative outcomes of SPLS with lateral ALIF vs. traditional supine ALIF with repositioning (FLIP) for degenerative pathologies. PURPOSE: To determine if SPLS with lateral ALIF improves perioperative outcomes compared to FLIP with supine ALIF. STUDY DESIGN/SETTING: Multicenter retrospective cohort study. PATIENT SAMPLE: Patients undergoing primary AP fusions with ALIF at 5 institutions from 2015 to 2020. OUTCOME MEASURES: Levels fused, inclusion of L4-L5, L5-S1, radiation dosage, operative time, estimated blood loss (EBL), length of stay (LOS), perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), and PI-LL mismatch. METHODS: Retrospective analysis of primary ALIFs with bilateral percutaneous pedicle screw fixation between L4-S1 over 5 years at 5 institutions. Patients were grouped as FLIP or SPLS. Demographic, procedural, perioperative, and radiographic outcome measures were compared using independent samples t-tests and chi-squared analyses with significance set at p <.05. Cohorts were propensity-matched for demographic or procedural differences. RESULTS: A total of 321 patients were included; 124 SPS and 197 Flip patients. Propensity -matching yielded 248 patients: 124 SPLS and 124 FLIP. The SPLS cohort demonstrated significantly reduced operative time (132.95 +/- 77.45 vs. 261.79 +/- 91.65 min; p <0.001), EBL (120.44 +/- 217.08 vs. 224.29 +/- 243.99 mL; p <.001), LOS (2.07 +/- 1.26 vs. 3.47 +/- 1.40 days; p <.001), and rate of perioperative ileus (0.00% vs. 6.45%; p =.005). Radiation dose (39.79 +/- 31.66 vs. 37.54 +/- 35.85 mGy; p =.719) and perioperative complications including vascular injury (1.61% vs. 1.61%; p =.000), retrograde ejaculation (0.00% vs. 0.81%, p =.328), abdominal wall (0.81% vs. 2.42%; p =.338), neuropraxia (1.61% vs. 0.81%; p =.532), persistent motor deficit (0.00% vs. 1.61%; p =.166), wound complications (1.61% vs. 1.61%; p =.000), or VTE (0.81% vs. 0.81%; p =.972) were similar. No difference was seen in 90-day return to OR. Similar results were noted in sub-analyses of single-level L4-L5 or L5-S1 fusions. On radiographic analysis, the SPLS cohort had greater changes in LL (4.23 +/- 11.14 vs. 0.43 +/- 8.07 deg; p =.005) and PI-LL mismatch (-4.78 +/- 8.77 vs.-0.39 +/- 7.51 deg; p =.002). CONCLUSIONS: Single position lateral ALIF with percutaneous posterior fixation improves operative time, EBL, LOS, rate of ileus, and maintains safety compared to supine ALIF with prone percutaneous pedicle screws between L4-S1. (C) 2021 Elsevier Inc. All rights reserved.