Anterior Spine Surgery Debate – Is It Over?

Which the venerable and esteemed Juan Uribe, M.D., Chief, Spinal Disorders, Sonntag Chair of Spine Research and Vice Chair, Neurosurgery at the Barrow Neurological Institute in Phoenix did in a recent LinkedIn post.

Dr. Uribe wrote: 5 things I hate about ALIF 😡 and then listed them, including a bonus point:

1. Risk of major vascular injury
2. Risk of retrograde ejaculation
3. Difficulty on revision cases due to scar around the major vessels
4. No possibility of direct neural decompression
5. Risk of sympathetic dysfunction (Hot/Cold legs)

Bonus: In the U.S., routinely relying on an access surgeon to perform the approach 😩

WOW, was there ever a reaction…starting with the Chief of Spine Surgery, The Warren Alpert Medical School of Brown University, the equally esteemed and venerable Alan Daniels, M.D., who responded saying:

5 things I love about ALIF:

• highest fusion rate at L5/S1 (challenging fusion level)
• best approach for restoration of foraminal height
• best approach for big lordosis correction
• best approach for restoration or lordotic apex/physiologic lordosis
• low complication rates when done by experienced ALIF team

And Dr. Daniels added: “All approaches have benefits and downsides. Vessel injury and retrograde ejac rate is low in high volume ALIF centers. Sympathetic issues are a definite downside, similar to thigh numbness/quad weakness in lateral fusion.”

Simon Sandler, M.D., Ralph Mobbs, M.D. and Stephen Hochschuler, M.D. immediately chimed in—supporting ALIF.

Then the dam broke. Responses poured in from all over the globe.

Here they are, in rough chronological order. It’s interesting reading.

Commentator

Comment

Ralph Mobbs, M.D. “I’ve done over 1,200 ALIFs and it is a remarkably robust procedure. The rate of retrograde ejaculation is well under 2% if you use blunt dissection laterally on L5/S1 and avoid unipolar = technique. It is the perfect operation for recurrent disc herniation and yes, you can decompress the neurological elements = technique. Big red & blue? Sure you can get into grief but be prepared for this = technique. Difficult revision cases I agree only done by those who are v experienced, but again = technique. Sympathetic? Sure…but not more than OLIF and almost always gets better in 3/12. When my L5/S1 goes to crap = I only want an ALIF. Simon Sandler, M.D. Best disc clearance and graft site preparation Thomas Errico, M.D. I was persuaded to get on the TLIF train and had marked increase in hardware and pseudo problems. Inherent to TLIF is destabilizing unilaterally the spine at that level which in short segments is not a problem but in long fusions at the bottom is undesirable. Alif’s worth the time and trouble and possibly additional short-term issues. Anthony Ghosh, M.D. Also having to work with a good vascular access surgeon is a bonus not a negative. Good teamwork. Allows the spine surgeon to focus on the spine and nerves Patrick Knight, M.D. This is the problem with approach surgeons as they have little responsibility to the patient. I think it’s better to do the approach oneself. Lali Sekhon, M.D., M.B.A. “How about the hassle of coordinating with the access surgeon when everyone wants him?? (also working on obese big-bellied people is like trying to fix something at the back of your freezer). Orlando Zamora, M.D. In my experience I never see a revision surgery for ALIF. There are more myths than real complications with vascular, sympathetic or ejaculation issues Compare how many revisions do you do in posterior vs anterior approach. Marcelo Perocca, M.D. Complications of the posterior route are much more frequent than the anterior! I had 300 cases of lumbar disc prosthesis and another 280 cases of ALIF and only 4 revisions without any complications due to this. Two cases of sympathetic dysfunction and no cases of retrograde ejaculation. The technique is more refined and without the muscle and bone damage of the posterior approach. Andrew Vivas, M.D. With respect to my great mentor, I disagree with point number four! Resection of the PLL, retrieval of sequestered disc fragments, resection of osteophytes, and direct decompression of ventrally, compressive elements within the foramen can be done through the disk space with a little bit of patience, practice, and skill. Just like a big ACDF Mike Selby, M.D. Andrew Vivas completely agree. Juan is wrong on this one. PLL release gives great visualization and is now routine for me in ALIF. If you can do an ACDF, you can release the PLL in an ALIF!! Jim Yousef, M.D. Andrew Vivas Agree 100%. Any remaining fragments will resolve or be treated with indirect decompression due to restored disc and foraminal height.

Agree 100% with Dr Daniel’s. MIS ALIF or lateral ALIF is preferable over TLIF or PLIF. Juan, why would you neglect the decades of work on lumbar lordosis correction or preservation with improved fusion rates? Your list of concerns has been addressed in the literature and most are negligible. Be well my friend!

Rao Prasanth, M.D. Mike Selby, I do it routinely too! Ray Ross, M.D. Once the annulus is reached in an ALIF it’s just an ACDF. I realised that in 1992 but pleased to learn some others have cottoned on. Pity it’s still about fusion and not replacement. And I don’t mean those technologies based on hips and knees- you need viscoelastic devices to improve on fusion. Robert Foster, M.D. Did my own exposure for years. Including thoracotomy and sternotomy L4-5 is the problem level, the complication rate is the same with an experienced spine surgeon, and an access surgeon. Dr. Holt has proven this. However, if you have a complication you can’t deal with, you will be criticized by your colleagues. The drawing shows the bifurcation of the aorta at 5-1 which is wrong. It’s almost always L3-4. The cable bifurcation is a little bit more midline and is usually right above the L5 S1. Space. The superior, hypo, gastric plexus, follows the vessels and is identifiable, there’s an arcane issue of surgery, and gynecology, that shows this. It is the ultimate minimally invasive surgery but is a pain in the ass. Zhi Wang In Canada: we do our own approach. You just do more and see more, like everything in surgery, your anxiety decreases after x number of cases. I think I got quite comfortable doing them even in patients with previous abdominal surgery at about 35-40 cases solo. With probably over 100 alif: one venous injury minor, one ejaculation problem. Touching wood!!! But I still try to do from posterior if I can. Charbel Moussallem, M.D. https://pubmed.ncbi.nlm.nih.gov/22275156/   ALIF is amazing Tim Rasmusson, M.D. I’m an access surgeon. Is that a bad thing???? Ryan DenHaese, M.D. Tim Rasmusson 14k approaches and counting! My man! Ryan DenHaese, M.D. ok 10k ALIF and rest LLIF…but who’s counting LOL. IMO…ALIF and LLIF are the best surgeries we do in Lumbar spine. Single level ALIF…. One of best surgeries we can do. Tim Rasmusson has done over 10k approaches for ALIF and published this data with limited Morbidity Bayram Cirak, M.D. Posterior is always better, safer and easier both for patients. And surgeon. İn case anterior fusion is a Must AxiaLif is a choice. Jake Timothy, M.D. There is no doubt an ALIF is a superior fusion procedure and created more lordosis. A lateral ALIF is even better. I regularly back up posterior, my question is this really necessary or will a standalone ALIF (with integrated screws) suffice. Simon Sandler, M.D. Standalone for almost everything.

1. 360 always for lytic spondy.

2. Think about 360 with degen spondy and high sacral slope/domed sacrum.

Mike O’Neill, M.D. Cunningham & Cappuccino et.al found standalone ALIF w/ 3 screws was equivalent to 360 A/P w/ ISOLA pedicle screws; and superior to Anterior Plate + IBD. No difference between 3 screw vs 4 screw stand-alone constructs.  No posterior tension band looks pretty awesome considering it avoids the incidence of facet impingement and subsequent adjacent level disease. What is more MIS than zero posterior muscle disruption?  What low back surgery would surgeons do on themselves or a loved one? Ioan Branea, M.D. To say that with ALIF there is no possibility of direct neural decompression is the same as to say one cannot decompress the cord or cervical nerve roots with ACDF Tanyo Hristov, M.D. Ioan Branea True! Feasible even in recurrent herniations Francis Kilian, M.D. We in Germany are used to perform the anterior approaches by ourself—but in difficult cases—revisions I always contact our vessel surgeons and we plan the intervention together. The risk of neural complications is higher by XLIF. Michael Coroneos, M.D. Yes with lateral approaches the vessels and ureter may not be seen until traumatized. Chaunchao Du, M.D. I really enjoy the post and discussion here, I think the main reason for the popularity of the poster approach is repeatability， low complication of big vessel or nerve injury, then is the insertion of Pedicle Screws. The advantages of anterior approach far surpass the posterior approach from the viewpoints of biomechanics. As for decompression, it can be well achieved with the assistance of the endoscopy. Puya Alikhani, M.D. Although a great surgery, it comes with its own risks, I have seen increased risk of DVT and foot drop due to over distraction in addition to risks mentioned by Dr. Juan Uribe, M.D. Samir Smajic, M.D. Which is easier: teaching an access surgeon how to perform an ALIF or teaching a spine surgeon how to perform an anterior access to L5/S1 and L4/5? That’s why I prefer to perform my own accesses. The real skill lies in mastering the anterior access technique and taking responsibility for the patient, even if it means forgoing an ALIF. Andrew Vivas, M.D. Dr. med. Samir Smajic I think there are many surgeons in the US (myself included) that would gladly do their own access, especially for straight forward cases. However, the medical-legal climate in the US is such that we cannot. Any complication would be very high risk of a lawsuit. Ray Ross, M.D. Retrograde ejaculation and ALIF Did you check on status pre-surgery? Did you use diathermy when you identified the sacral artery and vein? That’s a no. Did you identify filaments of the pre- sacral plexus and sweep them to one side with a peanut before you opened the annulus? indirect neural decompression is achieved by disc height restoration and entering the epidural space to remove posterior annulus any extruded disc material or osteophytes (rare because if a disc has reached this degree of degeneration it will be very stiff and restoration of disc height nearly impossible) I agree revision through scar is a tour de force. But under what circumstances are you forced to do that? If nonunion of ALIF (rare) just fuse posteriorly. Infection massive issue but fortunately rare. Post disc replacement fuse posteriorly but I’ve converted several to fusion – for revisions best to have a very experienced vascular surgeon doing the approach. You might have to divide the left common iliac vessels to gain safe access to 4/5 but they can be rejoined successfully like any sizeable blood vessel. Most of your issues can be minimized or overcome.

Fittingly and finally, a patient chimed in. Shawn Palmer, M.D., hip and knee surgeon at the University of Chicago Pritzker School of Medicine and a former anterior spine surgery patient, said, “I have one of those. Fifteen years out and love it. My back is the only thing that doesn’t hurt in the morning.”

Thanks to all of these remarkable surgeons for their timely, thoughtful, and thought-provoking comments.

And…feel free add your voice to the comments section below.