Indications and Contraindications for Anterior Lumbar Interbody Fusion and Posterior Instrumentation at L5-S1

Patient Selection Criteria

The American Association of Neurological Surgeons recommends that patients should have moderate, moderate-to-severe, or severe stenosis for laminectomy and fusion to be considered, which is not met in this case with only mild bilateral neuroforaminal narrowing at L5-S1 1, 2, 3
The presence of spondylolisthesis or radiographic instability is a primary indication for fusion in stenosis cases, but this patient has no documented spondylolisthesis and no evidence of gross movement on flexion-extension radiographs 1, 2, 3, 4

Intensive rehabilitation programs with cognitive behavioral therapy have Level II evidence showing equivalence to fusion for intractable low back pain without stenosis or spondylolisthesis, and should be offered to the patient 5, 6
The program should consist of education and exercises 5 days per week for 3 consecutive weeks, individually tailored and modified based on patient response, and include cognitive behavioral therapy to identify and overcome fears and unhelpful beliefs about pain 5, 6

Surgery would be appropriate if the patient develops moderate-to-severe stenosis on repeat imaging, or if spondylolisthesis or radiographic instability develops on flexion-extension films 1, 2, 3, 4
Decompression alone (without fusion) would be the appropriate surgical intervention if stenosis progresses, given the absence of instability 1, 2, 3