Neurological Complications Associated With Anterior Lumbar Interbody Fusion (ALIF): A Systematic Review

Introduction: Anterior lumbar interbody fusion (ALIF) is commonly used to treat lumbosacral pathologies, providing significant correction of lumbar lordosis and improving sagittal alignment. While perioperative complications such as vascular and visceral injuries are well-documented, there is limited literature on neurological complications in ALIF. This study aims to investigate the incidence and risk factors for neurological complications in ALIF through a systematic review.

Methods: A systematic review of literature published between January 2000 and June 2024 was conducted to identify studies reporting neurological complications associated with ALIF. Excluded studies included those evaluating lateral approaches, non-English articles, and abstracts without full text. Data collected included the type and incidence of neurological complications.

Results: A total of 28 articles met the inclusion criteria. Neurological complications included nerve root injury (radiculopathy and neurological deficit) and sympathetic nerve injury (retrograde ejaculation and post-sympathectomy dysfunction). The overall rate of neurological complications ranged from 1.8% to 9.4%. Nerve root injury rates for lumbar spine diseases were 0.1-3.8%, but higher in adult spinal deformity (ASD) studies, ranging from 7.1% to 38.4%. ALIF at L5-S1 was associated with L5 nerve root injury due to foraminal stenosis or nerve root stretch from hyperlordotic distraction. Reoperation rates for nerve root injuries following hyperlordotic ALIF at L5-S1 ranged from 1.8% to 8.3%. Reduced complication rates were reported with mini-open, retroperitoneal approaches, experienced access surgeons, neuromonitoring, and avoidance of recombinant human bone morphogenetic protein (rhBMP).

Conclusion : While neurological complications in ALIF are generally low, higher rates were observed in ASD cases. Careful surgical planning, particularly in hyperlordotic ALIF at L5-S1, is crucial to reduce the risk of nerve root injuries and the need for revision surgery.