Tag: mechanical complications

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Postoperative loss in segmental lumbar lordosis following L5–S1 anterior lumbar interbody fusion

J Neurosurg Spine 44:420–425, 2026

This clinical study evaluates predictors and thresholds for postoperative loss of L5–S1 segmental lordosis following anterior lumbar interbody fusion (ALIF) in 94 adults treated for degenerative disc disease. Multivariate analyses identified baseline obesity, absence of posterior fixation, and larger immediate lordotic correction as independent predictors of 6-week to 1-year segmental lordosis loss, which related to higher rates of cage subsidence and revision.

The authors derived 6-week postoperative L5–S1 lordosis thresholds (overall range 21.6°–26.8°, PI-specific: low 19.0°–24.8°, average 21.0°–26.4°, high 24.1°–28.7°) that minimized subsequent loss and need for revision. Findings support targeted preoperative planning to achieve sustainable correction while balancing risks of overcorrection and subsidence.

Segmental Lordosis Restoration: L5–S1 anterior lumbar interbody fusion (ALIF) provides strong and durable correction of segmental lumbar lordosis and disc height, with most correction maintained at 1 year postoperatively.

Predictors of Lordosis Loss: Baseline obesity, lack of posterior fixation, and larger initial correction in L5–S1 lordosis are independent predictors of postoperative segmental lordosis loss within 1 year.

Complications: Loss of segmental lordosis increases the risk of cage subsidence and revision surgery, particularly due to pseudarthrosis.

Optimal Correction Thresholds: Achieving 6-week postoperative L5–S1 segmental lordosis between 21.6° and 26.8° minimizes the risk of lordotic loss and need for revision; PI-specific thresholds are 19.0°–24.8° (low PI), 21.0°–26.4° (average PI), and 24.1°–28.7° (high PI).

Risks of Overcorrection/Undercorrection: Overcorrection (>26.8°) increases risk of cage subsidence and mechanical complications, while undercorrection (<21.6°) may predispose to implant failure and adjacent segment disease.

Surgical Planning Importance: Preoperative planning should target lordosis correction within these thresholds and consider modifiable risk factors to optimize outcomes and reduce complications.

Comparison to Other Techniques: ALIF offers greater segmental correction than other lumbar interbody fusion techniques such as TLIF or XLIF.

Clinical Implications: Nearly half of patients experience some degree of lordosis loss post-ALIF, highlighting the need for careful patient selection, surgical technique, and postoperative monitoring.

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Does Anterior Lumbar Interbody Fusion Reduce Mechanical Complication and Pseudarthrosis Rate at the Lumbosacral Junction in Adult Spinal Deformity Surgery in Comparison to Posterior Lumbar Interbody Fusion?

Int J Spine Surg 2025, 19 (4) 409-417

In adult spinal deformity surgery, anterior lumbar interbody fusion (ALIF) at the lumbosacral junction significantly reduces mechanical complications, pseudarthrosis, and reoperation rates compared to posterior lumbar interbody fusion (PLIF), suggesting ALIF should be preferred unless direct posterior decompression is necessary.

• ALIF (anterior lumbar interbody fusion) at the lumbosacral junction significantly reduces mechanical complications and pseudarthrosis rates compared to PLIF (posterior lumbar interbody fusion) in adult spinal deformity (ASD) surgery.

• ALIF is associated with lower rates of implant-related pain and reoperation than PLIF.

• PLIF is an independent risk factor for mechanical complications in long-segment ASD constructs.

• ALIF results in significantly less blood loss, fewer transfusions, and shorter ICU and hospital stays than PLIF.

• ALIF provides superior biomechanical stability and fusion rates, likely due to better endplate preparation and larger cage footprint.

• PLIF remains suitable for cases requiring direct neural decompression, such as severe stenosis or spondylolisthesis.

• Surgical technique selection should consider patient anatomy, surgical goals, and specific pathology at the lumbosacral junction.

• Study limitations include retrospective design, single-center data, and potential selection bias; further multicenter studies are needed.

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A survival analysis for predictors of implant subsidence following 1- or 2-level transforaminal lumbar interbody fusion

J Neurosurg Spine 43:42–51, 2025

This study found that after 1- or 2-level TLIF, aggressive disc height restoration and taller interbody implants significantly increase the risk of implant subsidence, especially in patients with poor bone quality. Surgeons should balance correction goals with subsidence risk, particularly in those with low Hounsfield unit measurements.

• This study analyzed predictors of interbody implant subsidence after 1- or 2-level transforaminal lumbar interbody fusion (TLIF) using a time-to-event (survival) analysis.

• Aggressive disc height restoration and use of taller interbody implants significantly increased the risk of subsidence.

• Poor baseline bone quality, measured by lower Hounsfield units (HU) on CT, was a strong independent predictor for significant (≥4 mm) subsidence.

• Longer fusion constructs (more instrumented levels) also increased the risk of significant subsidence.

• No significant association was found between cage material (titanium vs PEEK), device geometry, or lumbopelvic parameters and subsidence risk.

• Subsidence occurred in 38.2% of levels (≥2 mm) and significant subsidence in 10.4% (≥4 mm) by last follow-up.

• Clinical implications suggest balancing correction goals with subsidence risk, especially in patients with poor bone quality.

• Further multicenter and prospective studies are recommended to validate these findings.

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