Anterior Lumbar Interbody Fusion with Posterior Spinal Fusion for Vertebrogenic Low Back Pain

Evidence Supporting Surgical Intervention

The American College of Neurosurgery recommends anterior lumbar interbody fusion (ALIF) at L5-S1 with posterior spinal fusion (PSF) for patients with vertebrogenic low back pain who have failed non-operative care, as evidenced by persistent symptoms despite conservative management including physical therapy and injections 1, 2
Level II evidence supports lumbar fusion over traditional physical therapy alone for patients with intractable low-back pain who have failed conservative management, with a significant reduction in pain and improvement in functional outcomes 2, 3
Patients with significant degenerative disc disease at L5-S1, severe foraminal stenosis, and previous failed discectomy are considered appropriate candidates for fusion surgery, with a high likelihood of improved clinical outcomes 1, 3

ALIF provides better access to the L5-S1 disc space and allows for greater restoration of disc height and lordosis compared to posterior approaches alone, resulting in improved fusion rates and clinical outcomes 4, 5
ALIF with posterior instrumentation (360° fusion) has demonstrated higher fusion rates compared to posterolateral fusion alone, with a significant reduction in the risk of operative nonunion 4, 5, 6

The combined approach carries a higher complication rate (31%) compared to posterolateral fusion alone (6-16%), with potential complications including bleeding, nerve and vessel damage, infection, and failed fusion 6, 7
Specific complications related to the anterior approach may include iliac vein lacerations and sympathetic nerve injuries, emphasizing the need for careful patient selection and surgical technique 7

The decision to proceed with ALIF and PSF should be based on a thorough evaluation of the patient's clinical symptoms, radiographic evidence, and previous treatment history, including documented failure of physical therapy and injections 1, 2
Verification of radiographic evidence supporting fusion, including MRI showing significant degeneration at L5-S1 with Modic endplate changes and severe foraminal stenosis, is essential for determining the appropriateness of surgical intervention 4, 5