Anterior lumbar interbody fusion (ALIF)

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sion-alif-surgery
Modern Applications of ALIF Surgery

While the ALIF is still a widely available spine fusion technique, this type of
procedure is often combined with a posterior approach (anterior/posterior fusion
s) because of the need to provide more rigid fixation than an anterior approach
alone provides.

In cases where there is not a lot of instability, an ALIF alone can be sufficien
t. Generally, this is true in cases of one level degenerative disc disease where
there is a lot of disc space collapse.

For patients who have a "tall" disc, or for those with instability (e.g. isthmic
spondylolisthesis), an anterior approach to spinal fusion may not provide adequ
ate stability. In these clinical situations, the anterior lumbar interbody fusio
n may be supplemented with a posterior (from the back) instrumentation and fusio
n to provide additional support to the fused level of the spine.

An anterior lumbar interbody fusion, called a ALIF, is designed to stop the moti
on at the symptomatic segment of the spine.

An ALIF is done in the lumbar, or lower, spine. Most commonly it is performed on

the L4 through L5 or L5 through S1 segment at the bottom of the lumbar spine, a
s these segments are most likely to break down.

An ALIF is most commonly done to treat lumbar degenerative disc disease, in whic
h a degenerated disc becomes painful. It may be done for other indications and m
ay be combined with a posterior approach as well, if added stability is needed.

This type of fusion is unique as the surgery is done from the front, or anterior
.

It starts with a 3 to 5-inch long incision on the left side of the abdomen.

Next, the abdomen muscles are retracted to the side.

The abdominal contents lay inside a large sack (the peritoneum) that is then ret
racted to the side, allowing access to the front of the spine without actually e
ntering the abdomen.

The large blood vessels, called the aorta and vena cava, lay on top of the spine
, so a vascular surgeon will usually be part of the surgery to move the large bl
ood vessels to the side.

After the blood vessels have been moved aside, the disc material is removed.

Some type of implant, called a cage, is then inserted into the disc space. The c
age helps restore more of the normal spacing in between the vertebrae, alleviati
ng pressure on the nerve roots.

Bone graft is placed in the cage and sometimes in front of the cage.

Sometimes additional fixation is used by inserting screws through the cage.

If the patient's own bone graft is used, bone morsels are harvested from the fro
nt of the patient's iliac crest, or hip bone.

This is an additional surgical procedure that is done at the same time as the fu
sion surgery.

Synthetic bone graft options are may also be used.

In the months following the surgery, the bone graft heals together through and a
longside the cage, creating one long bone between the vertebrae and immobilizing
that segment of the spine.

An ALIF may be combined with a simultaneous posterolateral fusion, with an appro

ach from the back of the spine, if additional stability is needed to help ensure
a successful fusion.
Potential Risks and Complications with ALIF Surgery
There is a major risk that is unique to the ALIF approach. The procedure is perf
ormed in close proximity to the large blood vessels that go to the legs.
Damage to these large blood vessels may result in excessive blood loss. Quoted r
ates in the medical literature put this risk at 1% to 15%, although this should
be an uncommon complication in the hands of experienced vascular and spine surge
ons.
Other ALIF Considerations
In general, the principal risk of this type of spine surgery is that a solid fus

ion will not be obtained (nonunion) and further surgery to re-fuse the spine may
be necessary. Fusion rates for an ALIF should be as high as 90-95%.
Anterior Lumbar Interbody Fusion Spinal Implants and Bone Grafts
Although threaded titanium cages initially were the only spinal implants that we
re available, there is now an assortment of cages in different shapes, sizes and
materials.
Threaded Titanium Cage Limitations
One limitation with a threaded titanium cage is that the larger the size of the
disc space, the more bone that is removed from the subchondral endplates (the st
rong bone at the bottom and top of the vertebral body). This weakens the bone an
d leads to an increase in the subsidence rate (where the cages subside into the
vertebral body).
Indications and Contraindications for Anterior Cages
Because an anterior interbody spine fusion surgery relies on the strength of the
vertebral body to keep from subsiding, an absolute contraindication to doing an
anterior interbody fusion (without posterior supporting instrumentation) is ost
eoporosis. The cages do not fail by breaking. They fail because the bone in the
vertebral endplates may not be strong enough to support the cages. This leads to
a failure of the endplates, with the cage subsiding into the vertebral bodies.
In general, anterior cages are not strictly fixation devices for spine fusion. P
edicle screws used with posterior instrumentation systems provide excellent spin
al fixation. Anterior intervertebral devices should be thought of as an interfer
ence type of fixation. They are implanted in between the vertebral bodies and do
not strictly fixate the two vertebral bodies to each other. Until the bone knit
s them together, the cage is mostly held by an interference fit.
Because of this difference in mechanics, stand alone anterior fixation is best l
imited to collapsed disc spaces. It works better at L5-S1 where there is little
motion. At L4-L5, there is more flexion/extension motion, and this allows more m
otion through the cages. Lastly, they work better in one-level spine fusions tha
n two-level fusions, and most spine surgeons feel they should not be used as a s
tand alone device for three level fusions.
A problem with titanium cages has been that it is difficult to assess spine fusi
ons postoperatively because the metal impedes evaluation by x-ray. One solution
has been to use radiolucent cages (made of either carbon fiber or PEEK). Postope
ratively, the cages allow much better visualization of the healing bone. Unfortu
nately, they do not adhere to the bony endplates well and are rarely used by the
mselves. They are usually used in conjunction with either an anterior/posterior
fusion or a PLIF and supplemented with pedicle screws.
There are many innovations and technical improvements being developed, and altho
ugh no one cage is the best, there are certain cages that work well for certain
indications. As with any other spine fusion procedure, the implant used is large
ly dictated by what the treating spine surgeon prefers and has had the most succ
ess with in the past.
Whether a spine surgeon approaches the disc space from an anterior approach or f
rom one of the posterior approaches (PLIF, TLIF) is largely dependent on how com
fortable the surgeon is with the anterior approach and operating around the aort
a and vena cava.
Allograft Bone Grafts in ALIF Surgery
An ALIF spine surgery can also be done with an allograft bone implant. Allograft
bone (cadaveric bone) can be milled to a shape like a titanium implant (cylindr
ical), or more commonly, it is a femoral ring that can be shaped by the physicia
n to fit the disc space.
Generally, allograft bone is not as strong as other implants. In cases where the
lower back surgery is being done as an anterior/posterior approach, it may be s
trong enough, but most spine surgeons are leery about using it as a stand-alone
device (e.g. no posterior instrumentation to help support it). Allograft bone te
nds to cause resorption of the patient's own bone (osteolysis) at the graft/vert
ebral endplate interface early in the postoperative course, and can lead to furt
her instability.
In the past, the patient's own bone had been used (autologous bone graft). This

required a large bone graft to be taken from the patient's iliac crest, and had
a fairly high complication rate (such as postoperative chronic pain, infection,
pelvic fracture). Also, this bone is not all that strong or supportive as allogr
aft bone and required supplementation with posterior instrumentation.