• Manjot Singh, Mariah Balmaceno-Criss, Mohammad Daher, Renaud Lafage, D Kojo Hamilton, Justin S Smith, Robert K Eastlack, Richard G Fessler, Jeffrey L Gum, Munish C Gupta, Richard Hostin, Khaled M Kebaish, Eric O Klineberg, Stephen J Lewis, Breton G Line, Pierce D Nunley, Gregory M Mundis, Peter G Passias, Themistocles S Protopsaltis, Thomas Buell, Christopher P Ames, Jeffrey P Mullin, Alex Soroceanu, Justin K Scheer, Lawrence G Lenke, Shay Bess, Christopher I Shaffrey, Frank J Schwab, Virginie Lafage, Douglas C Burton, Bassel G Diebo, Alan H Daniels, and International Spine Study Group.
• Department of Orthopedics, Brown University, Providence, Rhode Island, USA.
• World Neurosurg. 2024 Sep 1; 189: e219e229e219-e229.

BackgroundSevere sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data are limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients.MethodsSevere adult spinal deformity patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and PROMs at baseline and 6-week postoperative visit were included. Patients were grouped into ALIF (1-2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1-2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs.ResultsAmong the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores, and radiographic spinopelvic parameters (P > 0.05). However, PSO was performed more often in revision cases (P < 0.001). Following surgery, L4-S1 lordosis correction (P = 0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (P = 0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (P < 0.001) and motor deficits (P = 0.049), and in-hospital ICU admission (P = 0.022) and blood products given (P = 0.004), but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and 6-week PROMs were comparable as well.ConclusionsALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intraoperative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment.Copyright © 2024 Elsevier Inc. All rights reserved.

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