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Sagittal Alignment After Lumbar Interbody Fusion: Comparing Anterior, Lateral, and Transforaminal Approaches

Watkins, Robert G. IV MD; Hanna, Robert BS; Chang, David MD; Watkins, Robert G. III MD

doi: 10.1097/BSD.0b013e31828a8447
Original Articles

Study Design: Retrospective radiographic analysis.

Objective: To determine which lumbar interbody technique is most effective for restoring lordosis, increasing disk height, and reducing spondylolisthesis.

Summary of Background Data: Lumbar interbody fusions are performed in hopes of increasing fusion potential, correcting deformity, and indirectly decompressing nerve roots. No published study has directly compared anterior, lateral, and transforaminal lumber interbody fusions in terms of ability to restore lordosis, increase disk height, and reduce spondylolisthesis.

Materials and Methods: Lumbar interbody fusion techniques were retrospectively compared in terms of improvement of lordosis, disk height, and spondylolisthesis between preoperative and follow-up lateral radiographs.

Results: A total of 220 consecutive patients with 309 operative levels were compared by surgery type: anterior (184 levels), lateral (86 levels), and transforaminal (39 levels). Average follow-up was 19.2 months (range, 1–56 mo), with no statistical difference between the groups. Intragroup analysis showed that the anterior (4.5 degrees) and lateral (2.2 degrees) groups significantly improved lordosis from preoperative to follow-up, whereas the transforaminal (0.8 degrees) group did not. Intergroup analysis showed that the anterior group significantly improved lordosis more than both the lateral and transforaminal groups. The anterior (2.2 mm) and lateral (2.0 mm) groups both significantly improved disk height more than the transforaminal (0.5 mm) group. All 3 groups significantly reduced spondylolisthesis, with no difference between the groups.

Conclusions: After lumbar interbody fusion, improvement of lordosis was significant for both the anterior and lateral groups, but not the transforaminal group. Intergroup analysis showed the anterior group had significantly improved lordosis compared to both the other groups. The anterior and lateral groups had significantly increased disk height compared to the transforaminal group. All the 3 groups significantly reduced spondylolisthesis, with no difference between the groups.

Marina Spine Center, Marina del Rey, CA

R.G.W. IV, has received funding from Marina Spine Center, is on the speaker’s bureau for Medtronic and Pioneer Surgical, and may receive royalties from Pioneer Surgical. R.G.W. III, has received funding from Marina Spine Center, has received royalties from Medtronic for other products, and may receive royalties from Pioneer Surgical. D.C. is on the speakers bureau for Pioneer Surgical. R.H. declares no conflict of interest.

Reprints: Robert G. Watkins IV, MD, Marina Spine Center, 4640 Admiralty Way, Suite 600, Marina del Rey, CA 90292 (e-mail:

Received August 29, 2012

Accepted January 8, 2013

© 2014 by Lippincott Williams & Wilkins, Inc.