Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study

Analysis of the Frequency of Intraoperative Complications in Anterior Lumbar Interbody Fusion: A Systematic Review

OBJECTIVE

We assessed the frequency of intraoperative complication rates related to access surgery, operating time, and intraoperative bleeding rates described in the literature for patients undergoing anterior lumbar interbody fusion (ALIF) to evaluate the adverse effects and, thus, help in therapeutic decision making and contribute to future clinical trials.

METHODS

A systematic review was conducted of MEDLINE and Embase databases in March 2023. The main inclusion criteria were adult patients aged >18 years, with no maximum age limit; the use of ALIF; the presence of quantitative data on intraoperative complications; and randomized controlled trials and cohort studies. Vascular and peritoneal injuries were considered primary endpoints. The operative time and intraoperative bleeding rate were secondary endpoints. Reports and case series, case-control series, systematic reviews, and meta-analyses were excluded.

RESULTS

Eight studies were included with a total of 2395 patients. We found important quantitative data for future randomized clinical studies involving ALIF surgery, including the rate of vascular lesions (2.79%) and peritoneal lesions (0.37%). In addition to these factors, only 4 of the 8 studies addressed the average surgery time, with a total average of 145.61 minutes. Furthermore, 6 of the 8 articles reported the mean rate of intraoperative bleeding, with a total mean blood loss of 272.75 mL.

CONCLUSIONS

ALIF is a lumbar spine access technique with low intraoperative complications. Patients with contraindications have a higher risk of complications. Randomized clinical trials are needed to assess the efficacy and safety of the procedure.

A retrospective analysis of perioperative complications of lateral approach lumbar interbody fusion in patients with prior abdominal surgery or a history of colonic inflammatory disease

BACKGROUND CONTEXT

Lateral approaches for lumbar interbody fusion (LIF) allow for access to the lumbar spine and disk space by passing through a retroperitoneal corridor either pre- or trans-psoas. A contraindication for this approach is the presence of retroperitoneal scarring that may occur from prior surgical intervention in the retroperitoneal space or from inflammatory conditions with fibrotic changes and pose challenges for the mobilization and visualization needed in this approach. However, there is a paucity of evidence on the prevalence of surgical complications following lateral fusion surgery in patients with a history of abdominal surgery.

PURPOSE

The primary aim of this study is to describe the association between surgical complications following lateral interbody fusion surgery and prior abdominal surgical.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients over the age of 18 who underwent lateral lumbar interbody fusion at a large, tertiary care center between 2011 and 2019 were included in the study.

OUTCOME MEASURES

The primary outcome included medical, surgical, and thigh-related complications either in the intraoperative or 90-day postoperative periods. Additional outcome metrics included readmission rates, length of stay, and operative duration.

METHODS

The electronic health records of 250 patients were reviewed for demographic information, surgical data, complications, and readmission following surgery. The association of patient and surgical factors to complication rate was analyzed using multivariable logistic regression. Statistical analysis was performed using R statistical software (R, Vienna, Austria).

RESULTS

Of 250 lateral interbody fusion patients, 62.8% had a prior abdominal surgery and 13.8% had a history of colonic disease. The most common perioperative complication was transient thigh or groin pain/sensory changes (n=62, 24.8%). A multivariable logistic regression considering prior abdominal surgery, age, BMI, history of colonic disease, multilevel surgery, and the approach relative to psoas found no significant association between surgical complication rates and colonic disease (OR 0.40, 95% CI 0.02-2.22) or a history of prior abdominal surgeries (OR 0.56, 95% CI 0.20-1.55). Further, the invasiveness of prior abdominal surgeries showed no association with overall spine complication rate, lateral-specific complications, or readmission rates (p>.05).

CONCLUSION

Though retroperitoneal scarring is an important consideration for lateral approaches to the lumbar spine, this study found no association between lateral lumbar approach complication rates and prior abdominal surgery. Further study is needed to determine the impact of inflammatory colonic disease on lateral approach spine surgery.

Risk Factors for Subsidence Following Anterior Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Anterior lumbar interbody fusion (ALIF) may be complicated by subsidence, which can lead to significant morbidity including pain, disc space collapse, neural compression, segmental kyphosis, instability, and vertebral body fracture. This study sought to identify patient and procedural risk factors for subsidence in patients undergoing ALIF.

METHODS

This study analyzed consecutive patients who underwent ALIF at a single institution with a minimum of 2 years follow-up. Patients were grouped as either Non-Subsidence (NS-ALIF) or Cage Subsidence (CS-ALIF) based on the final postoperative radiograph. Demographic variables, operative characteristics, and radiographic outcomes were evaluated to identify significant predictors on univariate and multivariate statistics.

RESULTS

144 patients (170 levels) were included with an average follow-up of 50.70 ± 28.44 months (4.23 years). The incidence of subsidence was 22.94% (39/170 levels). On univariate statistics, the CS-ALIF group was significantly older (P = .020), had higher BMI (P = .048), worse ASA (P = .001), higher prevalence of comorbid osteoporosis (P < .001), and a more anteriorly placed interbody device (P = .005). On multivariate analysis, anterior cage placement remained the only significant predictor (OR: 1.08, 95% CI: 1.03-1.14; P = .003). There was a significantly higher rate of subsequent adjacent segment surgery among the CS-ALIF group (P = .035).

CONCLUSION

Factors contributing to subsidence in ALIF included older age, higher BMI, severe ASA, and osteoporosis, while anterior cage placement remained the only independent predictor on multivariate analysis. Subsidence was associated with a higher rate of subsequent adjacent segment surgery. Surgical technique should optimize placement of the interbody cage and avoid overstuffing the disc space.

How to manage a ureteral injury after anterior lumbar spine interbody fusion surgery

BACKGROUND

Anterior lumbosacral interbody fusion (ALIF) surgery is a predominant approach used in various indications such as treating discogenic back pain, spondylolisthesis, degenerative lumbar scoliosis, intervertebral foraminal stenosis, or spondylolysis. In comparison with posterior conventional approach, ALIF surgery has several advantages: direct access to the spine without muscle dissection, reduced blood loss, decreased postoperative pain, and improved fusion rates. Rare complications following ALIF surgery need to be reported, therefore the authors present an uncommon case of a ureteral injury diagnosed early after surgery and its management.

MANAGEMENT OF A URINOMA

Herein, we present a case of a 35-year-old man who presented with abnormal abdominal pains 4 days after ALIF surgery. He was diagnosed with a distal left iatrogenic ureteral fistula on a contrast enhanced CT. After the initial endoscopic approach with double J stent and urinary catheter drainage insertion had failed, the injury was finally treated with ureterovesical reimplantation. At the last follow-up, the patient did well without any clinical or biological urinary sequelae after this grade IIIb complication on the Clavien Dindo Scale.

CONCLUSION

Although ureteral lesions during ALIF surgery are extremely uncommon, surgeons must be cautious when dissecting the retroperitoneal area. A methodical identification of the ureter might guarantee the security of each surgery, especially for patients who have undergone previous abdominal interventions.

The Role of Anterior Spine Surgery in Deformity Correction

There are a range of anterior-based approaches to address flexible adult spinal deformity from the thoracic spine to the sacrum, with each approach offering access to a range of vertebral levels. It includes the transperitoneal (L5-S1), paramedian anterior retroperitoneal (L3-S1), oblique retroperitoneal (L1-2 to L5-S1), the thoracolumbar transdiaphragmatic approach (T9-10 to L4-5), and thoracotomy approach (T4-T12). The lumbar and lumbosacral spine is especially favorable for anterior-based approaches given the relative mobility of the peritoneal organs and position of the vasculature.

Endovascular Repair of Iatrogenic Inferior Vena Cava and Iliac Vein Injury: A Case Series and Review of the Literature

OBJECTIVE

Iatrogenic injury to the large abdominopelvic veins can he highly morbid, and open surgical repair is technically challenging. Endovascular repair with covered stenting across the injured segment offers an alternative to open surgical management. We present a series of patients with operative injury to the inferior vena cava (IVC) and iliac veins who were treated utilizing an endovascular approach and review the available literature on this technique.

METHODS

A PubMed keyword and MeSH term search was performed, and titles were reviewed for relevance by the first author. Studies related to endovascular repair of iatrogenic injury to the IVC and iliac veins were then read in detail for possible inclusion in the review. Those deemed appropriate were further analyzed for interventional approach, stent type and size, technical success, post-procedural pharmacologic management, complications and surveillance strategy.

RESULTS

The initial search resulted in 6221 publications. A total of 17 met criteria for inclusion, all of which were case reports or series. Twenty-six patients were described as suffering iatrogenic injury to the IVC or iliac veins, treated with various types and sizes of stents. All cases achieved technical success with hemorrhage control. Procedural complications occurred in 15.4% of cases, including 3 cases of acute thrombus formation and 1 case of stenosis caudal to the initial stent edge requiring additional stenting. Two additional patients experienced stent occlusion in the surveillance period.

CONCLUSIONS

Endovascular repair of iatrogenic injury to the IVC and iliac veins can be an effective management option. However, due to limited data regarding this approach, many technical questions remain, including ideal size and type of stent graft, necessity and duration of post-procedural anticoagulant or antiplatelet therapy and appropriate surveillance. Additionally, long term outcomes in this population have not yet been described.

Study of quality of life and its correlated factors in patients after lumbar fusion for lumbar degenerative disc disease

Background

In the present work, we aimed to explore the correlated factors of quality of life in patients receiving lumbar fusion for lumbar degenerative disc disease (DDD) in China.

Methods

A total of 180 patients treated with lumbar fusion were included in the present study. Their general demographic characteristics, Visual Analog Scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, Simplified Coping Style Questionnaire (SCSQ), Social Support Questionnaire (SSQ), and Medical Outcomes Study Short Form 36 (MOS SF-36) were collected and evaluated preoperatively and at 1 year postoperatively.

Results

There were significant improvements in scores of VAS, JOA, and quality of life of patients from preoperation to 1-year postoperation after lumbar fusion. Marital status, with or without children, education level, economic pressure, and social support had significant predictive effects on the physical health of patients undergoing lumbar fusion. Marital status, education level, and economic pressure had significant predictive effects on the mental health of patients undergoing lumbar fusion.

Conclusions

Factors correlated with the physical health of patients after lumbar fusion included positive coping style, negative coping style, social support, age, education level (high school college), disease duration (5-10), suffering from other diseases (combined with two or more other disease) and the number of surgical segments (double and three or more). Factors correlated with the mental health included negative coping style, social support, age, education level (middle school and high school college) and the number of surgical segments (double and three or more). The results verify that these factors were correlated to the patient's quality of life after lumbar fusion. Emphasizing and selectively intervening these correlated factors can further improve the quality of life in patients receiving lumbar fusion for lumbar degenerative disc disease.

Anterior spine surgery for the treatment of complex spine pathology: a state-of-the-art review

The use of anterior spinal surgery for the treatment of spinal pathology has experienced a dramatic increase over the past decade. Long relegated to treat complicated anterior pathologies it has returned to mainstream spine surgery techniques for all types of conditions, providing a significant boost to the spine surgeons' armamentarium to address a wide variety of types of spinal diseases more effectively. Anterior surgery is useful whenever there is significant spinal pathology that requires direct visualization of the anterior vertebral column to best restore spinal alignment, structural integrity and neurologic function. These pathologies include spinal deformities, tumors, burst fractures, infections, vertebral avascular necrosis, pseudoarthrosis and other miscellaneous indications. Currently available approaches to the spine include transabdominal, paramedian retroperitoneal, lateral oblique retroperitoneal, thoracotomy, and thoracolumbar extensile. Most of the lumbar approaches are now done through a muscle splitting, minimalistic approach that has decreased their morbidity or more recently via tubular approaches, such as lateral lumbar interbody fusions or other ante-psoas approaches. New retractors, instrumentation, hyperlordotic implants, approved biologics and even image guidance for disc preparation and precise implant placement are all recent advances that will hopefully improve surgical outcomes in patients following anterior spinal surgery. Most importantly, these approaches require added expertise and training with a dedicated team consisting of an anteriorly trained spine surgeon working simultaneously with a dedicated vascular surgeon to ensure maximum safety and superior patient outcomes. This state of the review is dedicated to familiarizing practicing spine surgeons with the most commonly used anterior spinal approaches along with cutting-edge instrumentation and fusion techniques to improve their options for the treatment of difficult spinal pathologies.

Effect of Comprehensive Nursing on the Recovery of Gastrointestinal Function in Patients Undergoing Abdominal Operation

Objective

The objective is to explore the effect of comprehensive nursing on the recovery of gastrointestinal function in patients undergoing an abdominal operation.

Methods

Sixty patients undergoing abdominal surgery in our hospital from January 2019 to April 2021 were enrolled. The patients were arbitrarily assigned into control group and research group. The former group received routine nursing and the latter group received comprehensive nursing. Nursing satisfaction, gastrointestinal function, POMS-SF score, nutrition risk score, incidence of adverse reactions, and quality of life scores were compared.

Results

The nursing satisfaction of the research group was higher than that of the control group, and the difference between the groups was statistically significant (P < 0.05). In terms of gastrointestinal function, the anal exhaust time eating time defecation time and bowel sound recovery time in the research group were significantly lower than those in the control group, and the difference between the groups was statistically significant (P < 0.05). In terms of POMS-SF score, the scores of tension–anxiety, depression–depression, fatigue–dullness, anger–hostility, and confusion–confusion in the research group were lower than those in the control group, while the energy-vitality score was higher than that in the control group, and the difference between the groups was statistically significant (P < 0.05). There was no significant difference in nutritional risk score among patients before nursing (P > 0.05); after nursing, the nutritional risk score decreased. Compared between the two groups, the nutritional risk score of the research group was lower when compared to the control group at 3 days, 5 days, and 7 days after nursing, and the difference between the groups was statistically significant (P < 0.05). In terms of the incidence of adverse reactions, the incidence of adverse reactions such as incision effusion, incision infection, incision dehiscence, and anastomotic leakage in the research group was lower when compared to the control group, and the difference between the groups was statistically significant (P < 0.05). Regarding quality of life scores, before nursing, there exhibited no significant difference of patients (P > 0.05); after nursing, the quality of life scores of patients decreased. Compared with the two groups, the physical function, psychological function, social function, and healthy self-cognition scores of the research group were all lower compared to the control group, and the difference between the groups was statistically significant (P < 0.05).

Conclusion

Abdominal surgery patients received comprehensive care, which improved their mental health, reduced anxiety and depression levels, relieved fatigue and dullness, improved energy and vitality, and enhanced their overall mood. Meanwhile, it can also promote the recovery of gastrointestinal function in patients and reduce the incidence of adverse reactions.

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF).

SUMMARY OF BACKGROUND DATA

ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity.

METHODS

Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient.

RESULTS

A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades.

CONCLUSION

Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.

Study on Risk Factors and Nutritional Status of Postoperative Infection in Patients Undergoing Abdominal Surgery

In order to evaluate the risk factors of postoperative infection in patients undergoing abdominal surgery and the correlation with nutritional status, 143 patients admitted to our hospital for abdominal surgery from September 2020 to September 2021 are selected and analyzed. By collecting the clinical results and related pathological data of all patients, all patients are divided into the postoperative infection group (48 cases) and the noninfection group (95 cases) according to whether postoperative infection occurred. Firstly, the clinical data of the two groups are analyzed by univariate analysis. Secondly, the risk factors of postoperative infection in patients undergoing abdominal surgery are analyzed by binary logistic regression. Thirdly, the nutrition-related indexes are compared, and the correlation between postoperative infection and serum nutritional indexes is analyzed by the Spearman correlation coefficient. The results demonstrate that patients undergoing abdominal surgery have a certain risk of infection after surgery, and combination with underlying diseases is a risk factor for postoperative infection. In addition, poor preoperative nutritional status is also closely related to postoperative infection. It is suggested that serum PA and RBP indicators have certain predictive effects on postoperative infection.

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.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review

PURPOSE

To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach.

METHODS

PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance.

RESULTS

Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases.

CONCLUSIONS

Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.

Does the ACS NSQIP Surgical Risk Calculator Accurately Predict Complications Rates After Anterior Lumbar Interbody Fusion Procedures?

STUDY DESIGN

Clinical case series.

OBJECTIVE

The aim of this study was to determine the effectiveness of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator in the prediction of complications after anterior lumbar interbody fusion (ALIF).

SUMMARY OF BACKGROUND DATA

Identifying at-risk patients may aid in the prevention of complications after spine procedures. The ACS NSQIP surgical risk calculator was developed to predict 30-day postoperative complications for a variety of operative procedures.

METHODS

Medical records of patients undergoing ALIF at our institution from 2009 to 2019 were retrospectively reviewed. Demographic and comorbidity variables were entered into the ACS NSQIP surgical risk calculator to generate percentage predictions for complication incidence within 30 days postoperatively. The observed incidences of these complications were also abstracted from the medical record. The predictive ability of the ACS NSQIP surgical risk calculator was assessed in comparison to the observed incidence of complications using area under the curve (AUC) analyses.

RESULTS

Two hundred fifty-three (253) patients were analyzed. The ACS NSQIP surgical risk calculator was a fair predictor of discharge to non-home facility (AUC 0.71) and surgical site infection (AUC 0.70). The ACS NSQIP surgical risk calculator was a good predictor of acute kidney injury/progressive renal insufficiency (AUC 0.81). The ACS NSQIP surgical risk calculator was not an adequate predictive tool for any other category, including: pneumonia, urinary tract infections, venous thromboembolism, readmission, reoperations, and aggregate complications (AUC < 0.70).

CONCLUSION

The ACS NSQIP surgical risk calculator is an adequate predictive tool for a subset of complications after ALIF including acute kidney injury/progressive renal insufficiency, surgical site infections, and discharge to non-home facilities. However, it is a poor predictor for all other complication groups. The reliability of the ACS NSQIP surgical risk calculator is limited, and further identification of models for risk stratification is necessary for patients undergoing ALIF.Level of Evidence: 3.

Applied anatomy and surgical technique of the lateral single-position L5-S1 fusion

The latest development in the anterior lumbar interbody fusion (ALIF) procedure is its application in the lateral position to allow for simultaneous posterior percutaneous screw placement. The technical details of the lateral ALIF technique have not yet been described. To describe the surgical anatomy relevant to the lateral ALIF approach we performed a comprehensive anatomical study. In addition, the preoperative imaging, patient positioning, planning of the skin incision, positioning of the C-arm, surgical approach, and surgical technique are discussed in detail. The technique described led to the successful use of the lateral ALIF technique in our clinical cases. No lateral ALIF procedure needed to be aborted during these cases. Our present work gives detailed anatomical background and technical details for the lateral ALIF approach. This teaching article can provide readers with sufficient technical and anatomical knowledge to assist them in performing their first lateral ALIF procedure.