Purpose:

Over the past decade, alternative patient positions for the treatment of the anterior lumbar spine have been explored in an effort to maximize the benefits of direct anterior column access while minimizing the inefficiencies of single or multiple intraoperative patient repositionings. The lateral technique allows for access from L1 to L5 through a retroperitoneal, muscle-splitting, transpsoas approach with placement of a large intervertebral spacer than can reliably improve segmental lordosis, though its inability to be used at L5-S1 limits its overall adoption, as L5-S1 is one of the most common levels treated and where high levels of lordosis are optimal. Recent developments in instrumentation and techniques for lateral-position treatment of the L5-S1 level with a modified anterior lumbar interbody fusion (ALIF) approach have expanded the lateral position to L5-S1, though the positional effect on L5-S1 lordosis is heretofore unreported. The purpose of this study was to compare local and regional alignment differences between ALIFs performed with the patient in the lateral (L-ALIF) versus supine position (S-ALIF).

Methods:

Retrospective, multi-center data and radiographs were collected from 476 consecutive patients who underwent L5-S1 L-ALIF (n = 316) or S-ALIF (n = 160) for degenerative lumbar conditions. Patients treated at L4-5 and above with other single-position interbody fusion and posterior fixation techniques were included in the analysis. Baseline patient characteristics were similar between the groups, though L-ALIF patients were slightly older (58 vs. 54 years), with a greater preoperative mean L5-S1 disk height (7.8 vs. 5.8 mm), and with less preoperative slip (6.6 vs. 8.5 mm), respectively. 262 patients were treated with only L-ALIF or S-ALIF at L5-S1 while the remaining 214 patients were treated with either L-ALIF or S-ALIF at L5-S1 along with fusions at other thoracolumbar levels. Lumbar lordosis (LL), L5-S1 segmental lordosis, L5-S1 disk space height, and slip reduction in L5-S1 spondylolisthesis were measured on preoperative and postoperative lateral X-ray images. LL was only compared between single-level ALIFs, given the variability of other procedures performed at the levels above L5-S1.

Results:

Mean pre- to postoperative L5-S1 segmental lordosis improved 39% (6.6°) and 31% (4.9°) in the L-ALIF and S-ALIF groups, respectively (p = 0.063). Mean L5-S1 disk height increased by 6.5 mm (89%) in the L-ALIF and 6.4 mm (110%) in the S-ALIF cohorts, (p = 0.650). Spondylolisthesis, in those patients with a preoperative slip, average reduction in the L-ALIF group was 1.5 mm and 2.2 mm in the S-ALIF group (p = 0.175). In patients treated only at L5-S1 with ALIF, mean segmental alignment improved significantly more in the L-ALIF compared to the S-ALIF cohort (7.8 vs. 5.4°, p = 0.035), while lumbar lordosis increased 4.1° and 3.6° in the respective groups (p = 0.648).

Conclusion:

Use of the lateral patient position for L5-S1 ALIF, compared to traditional supine L5-S1 ALIF, resulted in at least equivalent alignment and radiographic outcomes, with significantly greater improvement in segmental lordosis in patients treated only at L5-S1. These data, from the largest lateral ALIF dataset reported to date, suggest that-radiographically-the lateral patient position can be considered as an alternative to traditional ALIF positional techniques.