ALIF Surgery: A Comprehensive Guide to Anterior Lumbar Interbody Fusion

What is ALIF surgery?

ALIF surgery is a specialized spinal fusion surgery that focuses on connecting (fusing) two or more vertebrae in the lumbar region of the spine, which is the lower L1-L5 vertebrae. It can also be used to fuse the L5 vertebrae (the lowest vertebrae in the lumbar spine) with the and S1 vertebrae (the top vertebrae in the sacrum).

During ALIF surgery, the surgeon accesses the spine through an incision made in the abdomen, rather than through the back posteriorly, which is done with TLIF, PLIF, and other common lumbar spinal fusion surgeries. The anterior approach allows surgeons to reach the affected area directly, minimizing disruption to the back muscles, nerves, and tissues.

When might ALIF be recommended?

The ALIF procedure may be recommended for patients who have not found relief with conservative treatments and interventional pain management and who have one of the following

• Degenerative Disc Disease: This condition is caused when the discs between the vertebrae deteriorate, causing pain and reduces
• Spondylolisthesis: In spondylolisthesis, one vertebra slips forward or backward onto the vertebra below i This causes instability and nerve compression. If more than half the width of the vertebra slips, patients may experience severe pain and need surgery.
• Disc Herniation: This condition occurs when a spinal disc bulges or ruptures and presses against nearby nerves, causing pain, numbness, or weakness.
• Failed Back Surgery Syndrome: For patients who have undergone previous spinal surgeries but have not found relief, ALIF may be recommended.
• Scoliosis and Lordosis: When the curvature of the spine causes pain and cannot be resolved with conservative treatment, fusion surgery may be considered.

How is ALIF performed?

At Neurosurgery One, we work closely with general or vascular surgeons who open the abdomen. Vascular surgeons have specialized expertise in ensuring abdominal veins and arteries are carefully navigated. Once the area of the spine is accessible, a neurosurgeon begins to remove the portion of the damaged disc and then places a cage device filled with bone graft that is either from a donor bank or another area of the patient’s body. Typically, the cage is held in place using a plate and screws. The bone graft will grow and create a fusion between the affected vertebrae. If necessary, a follow-up surgical procedure may occur in which the surgeon inserts screws and rods posteriorly (or through the back). This is usually planned for prior to the ALIF procedure and is often conducted 1-2 days after the first procedure.

Is there a minimally invasive option for ALIF surgery?

Yes, ALIF can be performed as a minimally invasive procedure (MIS ALIF).  When done as a minimally invasive technique, MIS ALIF minimizes tissue damage, reduces postoperative pain, and shortens recovery time.

Minimally invasive ALIF utilizes specialized instruments and small incisions (less than 5 centimeters, on average), resulting in less scarring and trauma to surrounding tissue, organs, and nerves. Additional benefits of the minimally invasive procedure include shorter hospital stays, reduced blood loss, and a faster return to daily activities.

What are the benefits of ALIF surgery compared to other lumbar fusion surgeries?

Properly identified patients with chronic lower back pain may have less pain, shorter recovery times, and greater improvement in spinal deformity correction with the ALIF procedure, compared to other fusion surgeries. During ALIF surgery, a surgeon accesses the spine via the anterior position (front) of the body through the abdomen. This avoids causing damage to the muscles in the back. The anterior approach also allows for a larger cage to be placed between vertebrae, which can provide greater stability and decompression.

Surgeons recommend specific lumbar interbody fusion procedures–ALIF, transforaminal lumbar interbody fusion (TLIF), or posterior lumbar interbody fusion (PLIF)–based on the patient and their condition.  When compared to other LIF procedures,  ALIF may provide:

• Better visualization of the L4/L5 and L5/S1 fusion levels
• Enhanced postoperative disc height, which is associated with better decompression of nerves
• Improved postoperative lordosis, or the normal curvature of the spine, which can lead to less pain and better long-term outcomes
• Less blood loss and shorter operating times for patients with spondylolisthesis

ALIF has also been found to cause less tissue, nerve, and spine bone damage, compared to other lumbar interbody fusion procedures. .

What are the potential risks and complications associated with ALIF surgery?

ALIF is considered a major spinal procedure due to its invasiveness and the need for general anesthesia. While risks involved with the procedure are low, the procedure carries potential side effects involved with any surgery, including infection, bleeding, nerve damage, and blood clots. Your surgeon will discuss these risks with you and take appropriate measures to minimize them. Here are some common concerns with ALIF:

• Pseudarthrosis, or non-union of the vertebrae that were fused. Research shows that this is a complication in less than 10% of ALIF cases. Neurosurgeons like those at Neurosurgery One have been able to reduce this risk to even less with proper patient selection and through our Spine Fracture and Bone Health Clinic
• Subsidence, or a decrease in disc height. Increasing disc height, not decreasing it, is a goal of all fusions. Roughly 10% of ALIF patients in this study had subsidence but it was not correlated with poor fusion rates
• Vascular complications, while rare, can arise from ALIF due to the anterior approach to surgery.Vascular complications are the most common complication of ALIF surgery. ALIF surgery targeting the L4-L5 area of the spine have higher rates of vascular complications, according to research.  Multi-level fusions and ALIF surgery performed on men also have a higher incidence of vascular complications, according to research published in the Journal of Vascular Surgery. Neurosurgery One always works with a general or vascular surgeon who is expert in vascular surgery to further reduce the risk of vascular complications.
• Adynamic postoperative ileus, or delayed post-operative bowel movement, is more than two times higher more likely in patients who undergo an anterior approach vs. a posterior approach. The risk of postoperative ileus in ALIF patient is between 3-5% but can be reduced by proper patient education, postoperative treatment, and pain management.
• Retrograde ejaculation is when semen enters the bladder instead of through the penis during ejaculation. Up to 45% of men who have laparoscopic ALIF experience retrograde ejaculation, compared to 6% of men who underwent a mini-open approach. This is why a mini-open ALIF approach is almost always recommended for men today.

How long does an ALIF surgery typically take?

The length of surgery can vary depending on the complexity of the case, the number of levels being fused, the patient’s health, and the condition being treated. On average, the ALIF procedure may take approximately 1-4 hours, and can take longer if the posterior surgery is performed immediately after the anterior procedure. Surgical time can vary for each individual patient and depends on your health, prior surgeries, and the vertebrae being targeted. Your surgeon will estimate the time your procedure will take prior to surgery and update your loved ones throughout the procedure should timing fluctuate.

Will I experience significant pain after ALIF surgery?

It is normal to experience some degree of pain and discomfort after ALIF surgery. However, your surgeon will prescribe appropriate pain medications to help manage any postoperative discomfort. Following their instructions for pain management and adhering to the recommended rehabilitation plan will contribute to a smoother recovery process and reduction in pain.

How long is the recovery period after ALIF surgery?

Surgery recovery always varies based on individual health factors, the condition being treated, and the extent of the surgery. Generally, patients can expect to spend 1-2 days in the hospital if they have undergone a minimally invasive procedure and do not need a follow-up posterior procedure. Patients have fewer surgical complications, recover faster, have shorter hospital stays, and have less opioid use when they participate in Neurosurgery One’s post-operative pain management and recovery process known as Enhanced Recovery After Surgery (ERAS).

Patients may need several weeks or months for a full recovery. Neurosurgery One makes sure all patients are up and moving the day after surgery. In general, you can likely return to work within a few weeks but are advised not to bend, lift or twist. You can enjoy light, low-impact walking, upright stationary bike, and treadmill activities the first 4 weeks post-surgery. After your 4-week post-surgery evaluation, you will likely start formal physical therapy and rehabilitate for up to 12 weeks. Keep in mind it can take up to 12 months for your bones to fully fuse together. Your surgeon will provide specific guidelines for post-operative care and rehabilitation.

Will I require physical therapy after the procedure?

Yes, physical therapy is recommended after ALIF surgery. Physical therapy plays a crucial role in the recovery process as it helps improve strength, flexibility, and overall function of the spine. Most patients begin their formal physical therapy treatment plan 4 weeks post-ALIF surgery. A physical therapist will guide you through exercises and rehabilitation techniques tailored to your specific needs and recovery goals.

How soon can I return to work after ALIF surgery?

You will be personally evaluated to determine how long you may need to recover from ALIF surgery before returning to work. Your job, the extent of your surgery, and how well your recovery progresses are all factors that play into your surgeon’s decision about when you can return to work. Most patients return to work within a few weeks. Patients with desk-based or sedentary jobs may be able to return to work earlier than those with more physically demanding jobs.

Are there any alternative treatments to ALIF surgery?

Whenever possible, conservative treatment options like physical therapy, medications, lifestyle changes, interventional pain management, and  injections will be considered before recommending ALIF surgery. Your spine specialist will evaluate your condition and discuss all available options with you to determine the most suitable treatment approach. This spine pain treatment map can help you understand the phases of back pain relief and where you may fall in the journey to finding pain relief.

Are there any long-term limitations or restrictions after ALIF surgery?

Like with any medical procedure, it is important for patients who undergo ALIF to follow your surgeon’s guidelines for post-operative care. Initially, you may be advised to avoid heavy lifting, bending, or twisting motions to protect the fused area for 4-12 weeks, based on how well your bones are fusing.. Over time, as your spine heals, your surgeon will provide instructions on gradually resuming normal activities and exercises. Learn more about common restrictions and complications after spinal fusion surgery and what to expect 6 months post after spine fusion surgery.

How successful is the ALIF procedure?

Every patient differs in their goals and expectations of what defines ALIF surgery success. ALIF surgery has been found to lead to  greater than 90% fusion success overall. The procedure also has been found to demonstrate higher fusion rates (above 94%) for patients with degenerative disk disease, spondylolisthesis, and failed posterior fusion. In general, the higher the fusion rates, the greater the patient satisfaction. While not always correlated, patients with higher fusion rates also experience less pain and greater quality of life.