Indications

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  Anterior lumbar interbody fusion (ALIF) is indicated as a treatment of chronic, incapacitating low back pain secondary to degenerative disk disease or degenerative spondylolisthesis in the absence of severe neural element compression. Patients are generally not considered for operation until at least 6 months of conservative nonsurgical therapies have failed to yield adequate amelioration of symptoms. ALIF may also be used in cases of failure of previous posterior approach lumbar surgery.

Contraindications

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  Assuming a patient’s general medical condition is adequate to undergo elective spine surgery, absolute contraindications to this procedure include conditions that limit retroperitoneal access to the lumbar spine, such as significant morbid obesity, retroperitoneal scarring from a previous surgery, or a large infrarenal aortic aneurysm and neural element compression requiring direct decompression. Direct decompression cannot be accomplished easily from an anterior approach, and in these cases a posterior procedure is required. A possible exception is radicular foraminal compression at the level of operation secondary to disk collapse, which may respond to distraction and restoration of disk height.

  
  
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  Relative contraindications include congenital or iatrogenic genitourinary anatomic abnormalities, such as an ipsilateral single ureter or kidney or a history of previous retroperitoneal surgery. Many patients who are unwilling to assume the risk of retrograde ejaculation are also better treated from a dorsal access route. Severe osteoporosis also limits the feasibility of interbody fusion because of the risk of graft subsidence.

Planning and positioning

For lower disk levels (L4-5, L5-S1), the patient is positioned supine on the operating table. An inflatable bladder is placed under the small of the back to increase or decrease lordosis as necessary. The surgeon can approach from the right side (patient in standard supine position). We typically use a cell saver in the event of large quantities of blood loss from vascular injury. A pulse oximeter is placed on each lower extremity to monitor for ischemia during vessel manipulation and retraction.

Before the incision, the correct disk space is localized using anteroposterior and lateral fluoroscopy, and the skin is marked appropriately. The incision for this approach corridor is centered at this location and marked.

Procedure

Although a transperitoneal approach may be used to access L4-5 and L5-1 disk spaces, the muscle-sparing retroperitoneal approach has become more popular because of lower rates of postoperative ileus, easier control of intraperitoneal structures, and ability to sweep the sympathetic plexus bluntly to the right of the disk space. Both approaches may be performed via various incisions, including the midline, paramedian, and Pfannenstiel incisions. A horizontal incision heals with better cosmesis, whereas a vertical incision allows for easier extension in the rostral-caudal plane. An approach from the left side is generally performed because gentle manual retraction of the aorta is more safely performed than retraction of the inferior vena cava, which can be difficult to repair surgically in the event of vessel wall injury.

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