JAAOS - 2026-06-16 - Journal Article
Anterior Lumbar Interbody Fusion Offers Safer Inpatient Profiles But at Greater Cost Compared With Posterolateral Fusion: National Outcomes for Spondylolisthesis From 2016 to 2022.
Mastrokostas LE, Mastrokostas PG, Inzerillo S, Razi A, Baek G, Houten JK, Varthi A, Ahn NU, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK, Saleh A, Bou Monsef J, Razi AE, Ng MK
Topics
Key Takeaway
ALIF for degenerative spondylolisthesis carries fewer perioperative complications than PLF (composite adverse events OR 1.68 favoring ALIF) but costs $11,500 more per admission ($43,000 vs. $31,500).
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Summary
This study used the National Inpatient Sample (2016–2022) to compare inpatient outcomes between ALIF and PLF for elective degenerative lumbar spondylolisthesis. In adjusted models, PLF carried higher odds of transfusion (OR 2.60), dural tear (OR 3.57), composite adverse events (OR 1.68), and nonroutine discharge (OR 1.19). ALIF had shorter LOS (2.81 vs. 3.31 days) but $11,500 higher mean inflation-adjusted costs.
Key Limitation
Absence of patient-reported outcomes, radiographic data (slip grade, sagittal alignment), and any follow-up beyond discharge makes it impossible to determine whether ALIF's inpatient safety advantage translates into superior functional recovery or long-term value.
Original Abstract
INTRODUCTION
Degenerative lumbar spine disease represents a leading global source of disability, with spondylolisthesis contributing substantially to the burden of low back pain and impaired function. Lumbar fusion remains a commonly performed surgical strategy for degenerative spondylolisthesis, although decompression alone versus decompression with fusion continues to be an area of active debate, particularly in select low-grade cases. This study aimed to compare inpatient complications, discharge disposition, mortality, and costs between anterior lumbar interbody fusion (ALIF) and posterolateral fusion (PLF) for degenerative lumbar spondylolisthesis.
METHODS
The National Inpatient Sample was queried from 2016 to 2022 for elective admissions of adults with a primary diagnosis of lumbar spondylolisthesis undergoing ALIF or PLF. Encounters with both approaches or additional interbody techniques were excluded. Outcomes included perioperative complications, in-hospital mortality, discharge disposition, length of stay, and inflation-adjusted costs. Survey-weighted logistic regression and generalized linear models adjusted for demographics, comorbidities, and hospital factors. Significance was set at the P < 0.05 level.
RESULTS
We identified 57,475 weighted admissions: 12,410 ALIF and 45,065 PLF. In adjusted models, PLF was associated with higher odds of transfusion (OR, 2.60; P < 0.001), acute posthemorrhagic anemia (OR, 1.47; P < 0.001), cerebrospinal fluid leak/dural tear (OR, 3.57; P < 0.001), and the adverse-events composite (OR, 1.68; P < 0.001). PLF also demonstrated greater odds of nonroutine discharge (OR, 1.19; P = 0.002). In-hospital mortality was exceedingly rare and not meaningfully different. ALIF was associated with higher mean costs ($43,000 vs. $31,500; P < 0.001) despite shorter length of stay (2.81 vs. 3.31 days; P < 0.001).
CONCLUSIONS
ALIF for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though at substantially higher inpatient costs. These findings highlight a clinical-economic tradeoff between anterior and PLF strategies at the national level.
LEVEL OF EVIDENCE
III.