Comparison of Outcomes of Multi-Level Anterior, Oblique, Transforaminal Lumbar Interbody Fusion Surgery : Impact on Global Sagittal Alignment

Abstract

Objective: To compare the outcomes of anterior lumbar interbody fusion (ALIF), oblique lumbar interbody fusion (OLIF), and transforaminal lumbar interbody fusion (TLIF) in terms of global sagittal alignment.

Methods: From January 2007 to December 2019, 141 adult patients who underwent multilevel interbody fusion for lumbar degenerative disorders were enrolled. Regarding the approach, patients were divided into the ALIF (n=23), OLIF (n=60), and TLIF (n=58) groups. Outcomes, including local radiographic parameters and global sagittal alignment, were then compared between the treatment groups.

Results: Regarding local radiographic parameters, ALIF and OLIF were superior to TLIF in terms of the change in the anterior disc height (7.6±4.5 mm vs. 6.9±3.2 mm vs. 4.7±2.9 mm, p<0.001), disc angle (-10.0°±6.3° vs. -9.2°±5.2° vs. -5.1°±5.1°, p<0.001), and fused segment lordosis (-14.5°±11.3° vs. -13.8°±7.5° vs. -7.4°±9.1°, p<0.001). However, regarding global sagittal alignment, postoperative lumbar lordosis (-42.5°±9.6° vs. -44.4°±11.6° vs. -40.6°±12.3°, p=0.210), pelvic incidence-lumbar lordosis mismatch (7.9°±11.3° vs. 6.7°±11.6° vs. 11.5°±13.0°, p=0.089), and the sagittal vertical axis (24.3±28.5 mm vs. 24.5±34.0 mm vs. 25.2±36.6 mm, p=0.990) did not differ between the groups.

Conclusion: Although the anterior approaches were superior in terms of local radiographic parameters, TLIF achieved adequate global sagittal alignment, comparable to the anterior approaches.

Keywords: Anterior lumbar interbody fusion; Lordosis; Lumbar vertebrae; Oblique lumbar interbody fusion; Spinal fusion; Transforaminal lumbar interbody fusion.

Fig. 1.

Changes in local radiographic parameters after multilevel lumbar interbody fusion according to the approaches. A : changes in anterior disc height. B : changes in posterior disc height. C : changes in foraminal height. D : changes in disc angle. E : changes in fused segment lordosis. ^*Negative values indicate lordosis. ALIF : anterior lumbar interbody fusion, OLIF : oblique lumbar interbody fusion, TLIF : transforaminal lumbar interbody fusion.

Fig. 2.

Changes in global sagittal alignment after multilevel lumbar interbody fusion according to the approaches. A : changes in lumbar lordosis. B : changes in pelvic incidence – lumbar lordosis. C : changes in pelvic tilt. D : changes in sagittal vertical axis. ^*Negative values indicate lordosis. NS : not significant, ALIF : anterior lumbar interbody fusion, OLIF : oblique lumbar interbody fusion, TLIF : transforaminal lumbar interbody fusion.

Fig. 3.

A 74-year-old woman underwent anterior lumbar interbody fusion (ALIF) at L4-S1. A and B : Preoperative and postoperative radiographs revealed an increased disc angle following ALIF. D and D : Preoperative and 1-year postoperative standing radiographs, respectively. Improvements in fused segment lordosis (FSL) (from -32.3° to -44.0°) and pelvic incidence (PI) (from 25.2° to 16.2°) were observed after surgery. However, the change in lumbar lordosis (LL) was trivial (from -45.1° to -45.3°), possibly due to a decrease in intraspinal compensation. PT : pelvic tilt, SVA : sagittal vertical axis.

Fig. 4.

A 66-year-old woman underwent oblique lumbar interbody fusion (OLIF) at L3-5. A and B : Preoperative and postoperative radiographs revealed an increased disc angle following OLIF. C and D : Preoperative and 1-year postoperative standing radiographs, respectively. Improvements in fused segment lordosis (FSL) (from -12.7° to -38.6°) and pelvic incidence (PI) (from 32.4° to 13.1°) were observed following surgery. Lumbar lordosis (LL) was markedly increased following surgery (from -25.1° to -46.4°). PT : pelvic tilt, SVA : sagittal vertical axis.

Fig. 5.

A 70-year-old man underwent transforaminal lumbar interbody fusion (TLIF) at L3-5. A and B : Preoperative and postoperative radiographs revealed an increased disc angle following TLIF. C and D : Preoperative and 1-year postoperative standing radiographs, respectively. Fused segment lordosis (FSL) (from -4.0° to -25.4°) was improved following surgery. Spinopelvic parameters, including lumbar lordosis (LL) (from -25.5° to -47.4°), pelvic incidence (PI) (from 21.3° to 18.9°), and sagittal vertical axis (SVA) (from 140.1 mm to -12.5 mm) were also improved following surgery. PT : pelvic tilt.