Lateral Decubitus Anterior Lumbar Interbody Fusion at the L4-5 Level is a Safe Alternative to Lateral Lumbar Interbody Fusion in One- to Two-Level Lateral Decubitus Single Position Surgery

Retrospective review of prospectively, consecutively enrolled patients. To assess differences in safety, efficiency and alignment between L-ALIF and LLIF at the L4-5 level in lateral single position surgery (L-SPS). The safety of L4-5 access in lateral lumbar interbody fusion (LLIF) may be limited by psoas, iliac crest, and vascular anatomy. Alternatively, lateral decubitus anterior lumbar interbody fusion (L-ALIF) can be used at the L4-5 level during L-SPS. Patients who underwent one to two-level L-SPS patients including L4-5 were analysed from seven institutions across three countries (Australia, Brazil, USA). Patients were grouped by the L4-5 interbody fusion technique: L-ALIF or LLIF. Demographics, procedural characteristics, complications, and sagittal alignment were analysed. Of 511 patients, 72 underwent L4-5 L-ALIF and 439 L4-5 LLIF. L-ALIF patients had more levels fused (1.65 vs. 1.25, P <0.001), longer operative time (115.78 vs. 89.08&#xa0;min, P <0.001), and length of stay (LOS) (2.41 vs. 1.71&#xa0;d, P <0.001). Propensity matching for demographics and levels fused (72 per group), demonstrated similar operative time (115.78 vs. 115.77&#xa0;min, P =0.998), LOS (2.41 vs. 1.98&#xa0;d, P =0.069), and blood loss (138.68 vs. 165.00&#xa0;mL, P =0.408). L-ALIF patients had less postoperative (4.2% vs. 21.6%, P <0.001) and minor complications (1.4% vs. 15.0%, P =0.001), mainly attributable to less transient thigh dysaesthesia (0.0% vs. 6.4%, P =0.028). Intraoperative complications (2.8% vs. 2.5%, P =0.892), major postoperative complications (2.8% vs. 8.9%, P =0.077), reoperations within 90 days (2.8% vs. 7.1%, P =0.170) and cage revisions (1.4% vs. 1.6%, P =0.896) were similar. L-ALIF more accurately restored L4-S1 regional lordosis (36.1&#xb0; vs. 29.7&#xb0;, P =0.017) postoperatively, and enabled larger improvement in L4-5 segmental lordosis (change of +6.8&#xb0; vs. +1.8&#xb0;, P <0.001). L-ALIF at L4-5 is a safe alternative to LLIF in L-SPS. In addition, L4-5 L-ALIF enables more accurate restoration of L4-S1 lordosis and effectively improves L4-5 segmental lordosis.