Review Question - QID 220513

Adult Isthmic Spondylolisthesis Techniques Anterior lumbar interbody fusion (ALIF) QID: 220513 (OBQ24.140)

QID 220513 (Type "220513" in App Search)

A 46-year-old male presents to the clinic with a chief complaint of lower back pain. He has longstanding lower back pain; however, 6 months prior, he had an increase in radicular pain down bilateral lower extremities and was diagnosed with adult isthmic spondylolisthesis. He had trialed activity modification, anti-inflammatories, and a trial of transforaminal epidural steroid injections 4 months prior. He received moderate relief lasting four weeks but is now interested in surgical intervention. His lateral lumbar films are shown in Figure 1. The surgeon recommends interbody fusion with posterior fixation. When counseling the patient regarding operative options, which is true when comparing anterior lumbar interbody fusion (ALIF) to transforaminal lumbar interbody fusion (TLIF)?

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ALIF results in greater restoration of disc height

59%

510/871

ALIF is associated with higher 1-year post-operative pain scores

9/871

ALIF and TLIF result in equivalent segmental lordosis

17%

148/871

ALIF is associated with a higher risk of postoperative complications

20%

171/871

ALIF is associated with a lower fusion rate

22/871

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Interbody fusion can be utilized in the treatment of adult isthmic spondylolisthesis that has failed appropriate nonoperative management. Several studies have shown ALIF results in improved segmental lordosis and restoration of disc height (answer choice 1).

Adult isthmic spondylolisthesis is subluxation of a vertebral body secondary to a defect in the pars interarticularis. Patients commonly present with axial back pain and radiculopathy. The radicular pain is caused by foraminal stenosis. Operative treatment involves stabilizing the subluxated vertebral body and decompression of the offending nerve root. After a posterior midline approach, lateral dissection and facetectomy can be used to perform a TLIF. This allows the surgeon to directly visualize and decompress the thecal sac, transversing and exiting nerve roots. ALIF is typically performed through a retroperitoneal approach, followed by transection of the anterior longitudinal ligament and placement of a large-footprint interbody cage. ALIF allows significant restoration of segmental lordosis with indirect decompression of neural elements. Either interbody options requires posterior fixation to prevent failure.

Lightsey et al. published the results of a retrospective cohort study of 70 patients treated in a single healthcare system for L5-S1 isthmic spondylolisthesis with either ALIF or posterior interbody fusion. At one year follow-up, patients in the ALIF group had a higher segmental and L4-S1 lordosis, greater increase in initial and final disc height increase, and more improvement in the physical domains of the Physical Function and Global Health assessment. The authors conclude that ALIFs generated greater segmental lordosis and restoration of disc height.

Tye et al. published the results of a retrospective cohort study of 66 patients who were treated for grade 1 or 2 L5-S1 isthmic spondylolisthesis with either ALIF or TLIF. ALIF patients showed a significantly greater improvement in segmental lordosis and disc height than TLIF. The ALIF group had a larger improvement in quality of life outcome scores, but neither group had an improvement that met the minimally clinically important difference. The authors concluded that ALIF produces better radiographic and clinical outcomes than TLIF.

Farber et al. published the results of a retrospective cohort study of 108 patients who were treated with either L5-S1 ALIF or TLIF. The cohorts did not significantly differ in complication rates, reoperation rates, or patient-reported outcomes. ALIF was associated with an increased segmental lordosis and neuroforaminal height. The authors conclude that patients treated with an ALIF at a single segment across the lumbosacral junction had better radiographic outcomes.

Figure 1 shows the lateral lumbar films of a patient with grade II L5-S1 spondylolisthesis.

Incorrect answers:
Answer 2: ALIF and TLIF have similar pain scores at one year after surgery.
Answer 3: Several studies have shown that ALIF has a significantly larger increase in segmental lordosis.
Answer 4: Although ALIF and TLIF have unique postoperative risks, the overall reported postoperative complication risk is similar.
Answer 5: Some studies have found ALIF to have a higher fusion rate, while others have found similar rates between ALIF and TLIF.