A systematic review of anterior lumbar interbody fusion (ALIF) versus posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), posterolateral lumbar fusion (PLF)

Purpose: To compare stand-alone anterior lumbar interbody fusion (ALIF) with posterior fusion techniques—posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), and posterolateral lumbar fusion (PLF)—in patients with degenerative disc disease (DDD) and spondylolisthesis via systematic review and meta-analysis. Methods: Systematic searches of Cochrane Register of Trials, MEDLINE, and EMBASE (inception–2022); two-stage independent screening by three reviewers; data extraction and quality assessment by two reviewers; random-effects meta-analyses. Results: From 16,435 records, 21 studies (n=3,686) were included (1 RCT; 20 non-randomized). ALIF showed significantly shorter surgical time and lower blood loss than TLIF/PLIF; no significant differences versus PLF for these metrics (p=0.08 for time). Length of stay was shorter with ALIF versus TLIF, but not versus PLIF/PLF. Fusion rates were similar between ALIF and all posterior approaches. PROMs were largely comparable between ALIF and PLIF/TLIF. Compared with PLF, ALIF showed better VAS back pain at 1 year (n=21, MD −1.00, CI −1.47 to −0.53) and 2 years (2 studies, n=67, MD −1.39, CI −1.67 to −1.11); ODI at 2 years favored ALIF (2 studies, n=67, MD −7.59, CI −13.33 to −1.85; I2=70%); JOAS low back pain favored ALIF at 1 year (n=21, MD −0.50, CI −0.78 to −0.22) and 2 years (n=67, MD −0.36, CI −0.65 to −0.07). VAS leg pain at 2 years favored PLF (n=46, MD 0.50, CI 0.12 to 0.88). Adverse events were similar across approaches. Conclusions: Stand-alone ALIF reduces operative time and blood loss relative to PLIF/TLIF and shortens hospitalization versus TLIF. Fusion and most PROMs are comparable to PLIF/TLIF, while several PROMs favor ALIF over PLF. Adverse event rates are comparable.