JAAOS - 2026-05-15 - Journal Article; Comparative Study
Anterior Versus Posterior Lumbar Fusion for Adult Isthmic Spondylolisthesis.
Frei A, Shahzad H, Callaway J, Bhale R, Higginbotham D, Vander Voort W, Roberto R, Khan S, Javidan Y, Le H
Topics
Key Takeaway
Posterior lumbar fusion for isthmic spondylolisthesis carries 2.65x higher odds of 90-day revision surgery compared to anterior lumbar fusion, despite lower readmission and ileus rates.
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Summary
This study used the PearlDiver database (2015–2022) to compare 90-day complications across ALIF (n=4,622), PLF (n=35,550), and combined AP fusion (n=3,447) for single-level isthmic spondylolisthesis. On multivariate analysis, PLF had lower readmission odds (OR 0.81) and lower ileus odds (OR 0.35) versus ALIF, but PLF (OR 2.65) and CLF (OR 2.40) both carried significantly higher odds of 90-day revision surgery. No significant differences were found in hematoma, pneumonia, sepsis, cauda equina syndrome, or DVT rates between cohorts.
Key Limitation
The 90-day window captures early surgical complications but cannot assess fusion rates, pseudarthrosis, adjacent segment disease, or functional outcomes, making it impossible to determine whether the higher PLF revision rate reflects a durable disadvantage or simply earlier detection of technical issues.
Original Abstract
INTRODUCTION
Surgical management for isthmic spondylolisthesis (IS) can be accomplished with either an anterior, posterior, or combined approach. This study compares 90-day medical and surgical complications of anterior, posterior, and combined lumbar fusion for adults with single-level IS.
METHODS
Deidentified patient data were obtained through the PearlDiver database using relevant ICD and current procedural terminology codes from 2015 to 2022. Patients ≥18 years with single-level IS who had undergone either anterior lumbar fusion (ALIF), posterior lumbar fusion (PLF), or combined AP lumbar fusion (CLF) were evaluated. Patients undergoing more than one level lumbar fusion were excluded, and 90-day postoperative complications were compared across cohorts.
RESULTS
Of 43,619 patients who underwent surgery for IS, 4,622 (10.6%) had ALF, 35,550 (81.5%) PLF, and 3,447 (7.90%) CLF. At 90 days postoperatively, multivariate analysis controlling for demographics, tobacco use, and obesity reveals that odds of readmission were significantly lower in patients who underwent PLF (odds ratio [OR] 0.81, P < 0.01) compared with ALF. A markedly higher odds of revision surgery was observed in patients undergoing PLF (OR 2.65) or CLF (OR 2.40) compared with ALF. Both PLF (OR 0.35) and CLF (OR 0.62) cohorts had lower odds of developing postoperative ileus. No significant difference was noted in rate of postoperative hematoma, pneumonia, sepsis, cauda equina syndrome, or deep vein thrombosis at 90 days between PLF or CLF cohorts compared with ALF (P value >0.05).
CONCLUSION
Among adult patients with IS undergoing single-level lumbar fusion, 81.5% had posterior surgery while 7.9% had combined AP surgery. Compared with the anterior approach, patients undergoing the posterior approach had lower 90-day readmission rates and postoperative ileus rates. However, patients undergoing posterior or combined surgery had higher odds of requiring revision surgery within 90 days. These differences in complication profile may help surgeons in surgical decision making on which approach to consider in their patients with IS.