Comparison of the safety outcomes between two surgical approaches for anterior lumbar fusion surgery: anterior lumbar interbody fusion (ALIF) and extreme lateral interbody fusion (ELIF)

Purpose To review the evidence on safety of anterior lumbar interbody fusion (ALIF) and extreme lateral transpsoas interbody fusion (ELIF) in the treatment of degenerative spinal disorders with an emphasis on the association between neuromonitoring and complications. Methods We performed a systematic literature search in the Cochrane (CENTRAL), MEDLINE, EMBASE and the FDA Medical Devices databases. We abstracted information on study design, sample size, population, procedure, number and location of involved levels, follow-up time and complications, as well as information on conflict of interest and source of funding. In addition, for ELIF we collected information on the use of neuromonitoring during the procedure. Results 34 publications were included in the review: 24 ELIF (all case series), 9 ALIF (8 randomized controlled trials and 1 case series) and one retrospective cohort that directly compared ELIF with ALIF. 18 out of 24 ELIF studies reported using neuromonitoring. The overall complication rate for ELIF was lower compared to ALIF without FDA reports (16.61 vs. 26.47 %, respectively). However, the rate of neurologic complications in ELIF was almost twice as high compared to ALIF without FDA reports (8.92 and 4.96 %, respectively). The rate of overall complications in ELIF studies that were reported using neuromonitoring was lower compared to the studies that did not report using neuromonitoring (16.34 vs. 21.74 %, respectively). Conclusion Although the overall complications rate for ELIF was lower compared to ALIF, ELIF is associated with a greater risk of neurological complications compared to ALIF even when used with neuromonitoring.