Onishi Franz Jooji, de Vasconcelos Vladimir Tonello
Federal University of São Paulo, São Paulo, Brazil.
Eur Spine J. 2025 May 22. doi: 10.1007/s00586-025-08914-w.
Over the past years, there has been an upward trend in the total number of spinal fusion procedures worldwide. There are many different strategies to perform the lumbar fusion, each with some advantages. Hospital charges for lumbar spinal surgeries also have increased significantly, with great variation in the costs and recommendations of different surgical procedures. There has also been a trend increase in the rate of the use of interbody fusion implants compared to that of traditional decompression surgery, even though the former is known to incur higher costs. Access through the anterior route gained many followers after studies on sagittal balance, and its indication has also increased worldwide. However, this technique presents different patterns of complications from those observed in traditional posterior approaches.
This study aims to determine the safety and efficacy of surgery in managing patients with symptomatic lumbar degenerative diseases by comparing the effectiveness of posterior and anterior approach techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative complication data.
A systematic search of multiple online databases was conducted up to August 2024 to identify randomized controlled trials (RCTs) and other high-quality retrospective studies comparing outcomes of anterior lumbar interbody fusion (ALIF) versus posterior fusion techniques (PLF, PLIF, TLIF) in the treatment of degenerative lumbar diseases. The primary outcomes assessed included the Oswestry Disability Index, Visual Analogue Scale, and overall clinical improvement. Secondary outcomes encompassed complications such as mortality, infections, gastrointestinal complications, deep vein thrombosis (DVT), surgical site infections, and the need for blood transfusions, as well as length of hospital stay and operative duration. Pooled effect estimates were calculated and presented as mean differences (MD) with 95% confidence intervals (CI) at the two-year follow-up.
Regarding VAS and ODI, anterior and posterior approaches were similar in analyzing five RCTs. Including retrospective studies, we also found that the length of hospital stay and duration of surgery were comparable between the two approaches. Anterior approaches had a lower rate of patients requiring blood transfusions OR 0,69[0.60,0,80]. Anterior approaches showed higher rates of mortality (0,21%) OR1,33[1.10,1.62], deep vein thrombosis (0,65%) 1.73 [1.35, 2.20], and gastrointestinal complications (4,9%) OR 2.19 [1.73, 2.78].
Clinical outcomes measured by VAS and ODI were comparable between anterior and posterior approaches, demonstrating similar efficacy in treating lumbar degenerative diseases. However, the safety profiles varied significantly. Anterior approaches carried higher rates of severe complications, including mortality, DVT, and gastrointestinal events, while posterior techniques were linked to increased blood transfusion needs. Given the elevated risk of severe complications with ALIF, posterior approaches should be prioritized as the first-line option for lumbar degenerative disease.
在过去几年中，全球脊柱融合手术的总数呈上升趋势。进行腰椎融合有许多不同的策略，每种策略都有一些优点。腰椎手术的医院收费也显著增加，不同手术程序的成本和建议差异很大。与传统减压手术相比，椎间融合植入物的使用率也呈上升趋势，尽管前者成本更高。在对矢状面平衡进行研究后，前路手术获得了许多追随者，其适应证在全球范围内也有所增加。然而，与传统后路手术相比，该技术呈现出不同的并发症模式。
本研究旨在通过比较后路和前路手术技术治疗有症状的腰椎退行性疾病的有效性，确定手术治疗此类患者的安全性和有效性。我们还旨在通过纳入围手术期并发症数据来研究这些手术干预的安全性。
截至2024年8月，对多个在线数据库进行了系统检索，以识别比较前路腰椎椎间融合术（ALIF）与后路融合技术（PLF、PLIF、TLIF）治疗退行性腰椎疾病疗效的随机对照试验（RCT）和其他高质量回顾性研究。评估的主要结局包括奥斯威斯功能障碍指数、视觉模拟评分和总体临床改善情况。次要结局包括并发症，如死亡率、感染、胃肠道并发症、深静脉血栓形成（DVT）、手术部位感染、输血需求，以及住院时间和手术持续时间。计算合并效应估计值，并在两年随访时以95%置信区间（CI）的平均差（MD）表示。
关于视觉模拟评分（VAS）和奥斯威斯功能障碍指数（ODI），在分析五项随机对照试验时，前路和后路手术相似。纳入回顾性研究后，我们还发现两种手术方式的住院时间和手术持续时间相当。前路手术患者输血需求率较低，比值比（OR）为0.69[0.60,0.80]。前路手术的死亡率较高（0.21%），OR为1.33[1.10,1.62]，深静脉血栓形成率为（0.65%），OR为1.73[1.35,2.20]，胃肠道并发症发生率为（4.9%），OR为2.19[1.73,2.78]。
通过VAS和ODI衡量的临床结局在前路和后路手术之间具有可比性，表明在治疗腰椎退行性疾病方面疗效相似。然而，安全性概况差异显著。前路手术严重并发症发生率较高，包括死亡率、深静脉血栓形成和胃肠道事件，而后路技术与输血需求增加有关。鉴于前路腰椎椎间融合术严重并发症风险较高，后路手术应优先作为腰椎退行性疾病的一线选择。
