Spine - 2026-05-15 - Journal Article; Systematic Review; Meta-Analysis; Comparative Study
Open Versus Percutaneous Posterior Fixation Following Anterior or Lateral Lumbar Interbody Fusion : A Systematic Review and Meta-Analysis.
Sadh P, Sheth S, Greenberg M, Khan Z, Tripathi P, Khan N, Basques BA
Topics
Key Takeaway
Percutaneous posterior fixation after ALIF/LLIF reduces EBL by 387 mL, OR time by 65 minutes, and LOS by 1.7 days versus open fixation, while open fixation achieves 12.9° greater lumbar lordosis correction in adult spinal deformity cases.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This PRISMA-compliant systematic review and meta-analysis compared open versus percutaneous posterior fixation following ALIF or LLIF across 13 comparative studies. Percutaneous fixation demonstrated significant perioperative advantages including 387 mL less EBL, 65 fewer operative minutes, 1.7-day shorter LOS, and fourfold reduction in transfusion risk, with superior early ODI improvement that persisted at 2 years. Open fixation produced significantly greater sagittal correction in ASD subgroups (ΔLL 12.9°, PI-LL improvement 4.1°), with no between-group differences in fusion rates, reoperation, or adjacent segment disease.
Key Limitation
The ASD subgroup driving the open fixation sagittal correction advantage is not uniformly defined across included studies, introducing selection bias that may conflate deformity severity with approach choice.
Original Abstract
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To compare perioperative, radiographic, and functional outcomes between open and percutaneous posterior fixation following anterior or lateral lumbar interbody fusion (ALIF/LLIF).
BACKGROUND
Posterior fixation enhances construct stability after ALIF or LLIF, yet the optimal approach, open versus percutaneous, remains debated. While minimally invasive surgery (MIS) reduces tissue disruption, open fixation may offer superior sagittal correction, particularly in adult spinal deformity (ASD). Prior meta-analyses have not isolated ALIF/LLIF procedures.
MATERIALS AND METHODS
Following PRISMA guidelines, PubMed, Embase, and Google Scholar were searched (January 2000-January 2025). Comparative studies evaluating open versus percutaneous posterior fixation after ALIF/LLIF were included. Outcomes included sagittal parameters, perioperative variables, postoperative events and patient-reported outcomes. Meta-analyses were performed using random- or fixed-effects models depending on heterogeneity ( I2 >50%).
RESULTS
Thirteen studies (912 patients; 454 open, 458 percutaneous) met inclusion criteria. For radiographic outcomes: No overall difference in Δ lumbar lordosis (LL), Δ pelvic incidence-LL, or Δ sacral slope; however, open fixation achieved greater sagittal correction in ASD (ΔLL=12.9° [95% CI: 0.01-25.87, P =0.05], PI-LL=-4.1° [95% CI: -7.88, -0.38, P =0.03], SS=+2.5° [95% CI: 0.38-4.58, P =0.02]). For perioperative outcomes, percutaneous fixation reduced EBL (-387 mL [95% CI: -575.72, -197.71, P <0.0001]), OR time (-65 min [95% CI: -93.90, -15.82, P =0.006]), LOS (-1.7 d [95% CI: -2.42, -1.01, P < 0.00001]), and transfusion risk (OR: 0.26 [95% CI: 0.11-0.58, P =0.001]). For postoperative outcomes, no significant differences in reoperation, fusion, or adjacent segment disease incidence; percutaneous fixation improved pain-medication independence (OR: 4.29 [95% CI: 1.20-15.36, P =0.03]). For patient-reported outcomes, percutaneous fixation yielded superior ODI (-7.1 [95% CI: -11.07, -3.21, P =0.0004]) improvements early; at 2 years, it maintained minimally better VAS back (-0.31 [95% CI: -0.54, -0.08, P =0.009]) and ODI (-2.9 [95% CI: -5.04, -0.68, P =0.01]) scores.
CONCLUSIONS
Percutaneous posterior fixation after ALIF/LLIF offers clear perioperative advantages, reduced blood loss, operative time, LOS, and transfusion need, without compromising fusion or long-term outcomes. Open fixation remains preferable for ASD cases requiring extensive sagittal realignment. Surgical approach should therefore be individualized based on deformity rigidity and alignment goals.