Few data are available to evaluate approach-related differences in perioperative complications with lumbar interbody fusion devices. Complications occurring in the intraoperative and immediate postoperative period were identified and categorized for 31 consecutive posterior lumbar interbody fusions (PLIFs) and 88 consecutive anterior lumbar interbody fusions (ALIFs). In this study, all lumbar interbody fusions were conducted with threaded cylindrical devices as stand-alone internal fixation devices. Multivariate analysis was used to account for potential covariates and identify factors associated with an increased complication risk. Twenty-two percent of the patients had a perioperative complication. The relative risk of having a perioperative complication was 4.75 times higher for the PLIF group. All intraoperative complications occurred in the PLIF group. The relative risk of having a major postoperative complication was 6.8 times higher in the PLIF group than the ALIF group. Anterior approached patients tended to have visceral (ileus, 6%) and vascular (deep venous thrombosis, 2%) complications. In the posterior group, complications were neurologic and dura related (pseudomeningocele, 16%; epidural hematoma, 3%) and occurred most frequently in patients that had had previous posterior lumbar surgery (31% with major complication).
The technique of lumbar interbody fusion has been used since the 1940s to manage degenerative conditions of the lumbar spine. 1,2 However, technical difficulties with bone graft displacement, collapse, and failure subsequently tempered enthusiasm for interbody fusion. 3,4 The recent development of interbody fixation devices known as cages has renewed interest in lumbar interbody fusion. 5,6 These cages are specifically designed to prevent graft dislodgement and provide mechanical support. 7-10
Several studies have reported promising results of interbody cages for the treatment of chronic discogenic back pain. 6,11-13 Theoretical advantages of cage fusion over other forms of lumbar segmental fusion include compression loading of the graft material and restoration of the anatomic disk space. 14-16
Currently, surgeons' choices of an anterior or posterior approach for lumbar interbody fusion may be influenced by their familiarity with either technique. Each approach has unique theoretical risks and advantages. The anterior (retroperitoneal or transperitoneal) approach is performed in proximity to the ureter, peritoneum, and great vessels. Several large sacral and lumbar segmental vessels often require ligation, and the great vessels may need to be retracted for part of the case. The posterior approach requires bilateral laminotomies with partial or complete facetectomies and foraminotomies followed by careful retraction of the dural sheath and nerve roots. 17,18 Some investigators have noted that complications associated with interbody fusion are often due to the approach rather than hardware failure. 27,28 Wetzel and LaRocca 29 noted extensive epineural fibrosis in 12 patients who underwent revision surgery after failed posterior lumbar interbody fusion (PLIF); they concluded that this fibrosis was the result of extensive retraction of the nerve roots. Identifying the immediate operative-related risks of instrumented interbody fusion can provide useful information for approach selection. Knowledge of approach-specific complications can also aid in preoperative patient counseling and ensure early recognition of infrequent but serious complications.
The purpose of this retrospective analysis is to identify the type and rate of complications of instrumented interbody fusion occurring during the perioperative period and evaluate differences that may exist between an anterior and a posterior approach.