L1–L5 anterior lumbar interbody fusion: anatomical and technical considerations: a narrative review

Introduction

L3–L4, L4–L5 and L5–S1 motion segments are most commonly affected by lumbar degeneration (1-3), with L4–L5 and L5–S1 being the commonest of these levels. Disc herniation is the commonest presentation of degenerative disc disease with prevalence at L4–L5 exceeding L1–L4, and L5–S1. Degenerative disc disease is relatively uncommon at L1–L2 (4), unless aggravated by trauma or conditions such as scoliosis. It has been reported that mean age for patients presenting with disc degeneration at L1–L4 levels is significantly higher than L4–S1 (5). Thus, it is evident that older patients present with degeneration at a higher level, i.e., L1–L4, whereas patients with disc degeneration at L4–S1 are relatively younger (6,7). The severity of disc degeneration progressively increases from proximal L1–L2 intervertebral disc to L5–S1. This correlates well with the lower Modic type 2 changes seen at L1–L2 as compared to significantly increased changes at L5–S1 (8).

Owing to exceptional visualisation and clear access to the ventral surface of the disc, Anterior lumbar interbody fusion (ALIF) is an excellent procedure for fusion of L4–S1 but with additional vascular mobilisation can be used at more proximal levels. Anatomically it can restore the disc height and lordosis while providing a large graft area and resultant high fusion rates with a reduced risk of dural injuries when compared to posterior procedures (9-12). The most common operative level is L5–S1 followed by L4–L5 which corroborates well with the affection of these level with degenerative disease aetiologically (13). This review determines the anatomical and technical considerations required for performing ALIF. We present this article in accordance with the Narrative Review reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-132/rc).

Methods

As indicated in Table 1, review of literature relevant to ALIF and associated surgical technique, anatomical and technical considerations for reconstruction of the anterior column by ALIF at the L1–L5 level was conducted from the 1st of June to the 1st of July 2024. Literature was obtained by using the following databases SCOPUS, PubMed, Medline, EMBASE, OVID, and Cochrane. The timeframe set was to 2024 inclusive. All non-English articles were excluded.

Discussion

Indications

ALIF is indicated primarily in lumbar disc degeneration presenting with the symptoms of low back pain with or without radiculopathy. The other indications are spondylolisthesis (degenerative or isthmic), lateral listhesis, iatrogenic segmental instability, and pseudoarthrosis (14,15). These indications commonly affect the lower lumbar levels of L4–S1, and trauma or pathological conditions such as scoliosis usually affect the proximal lumbar discs.

The proximal lumbar discs involved with thoracolumbar junction trauma is an important consideration as Seibenga et al. reported 78% of junctional injury due to horse riding with spinal injuries (16). Another important indication involving upper part of the lumbar spine is pathological disc degeneration, scoliosis and spinal stenosis with Achondroplasia. A higher degree of disc degeneration was observed at L1–L4 intervertebral levels in cases of achondroplasia (17).

Approach

Retroperitoneal exposure of the lumbar spine for spinal fusion techniques anteriorly have now become a standard and safe procedure for L2–L5 ALIF. A transperitoneal approach is an alternative when retroperitoneal dissection is limited, offering a wider field and easier vessel mobilisation but with higher rates of ileus and visceral complications (18). Laparoscopic ALIF applies minimally invasive principles with smaller incisions, less muscle trauma, and reduced blood loss, though it requires specialised equipment, longer operative times, and favourable anatomy (19). The retroperitoneal corridor is the preferred approach for L2–L5 ALIF as it provides efficient vascular access to the mid and lower lumbar disc space along with providing a wide visualisation that assists with disc space clearance is possible with left retroperitoneal approach anteriorly with the patient in the supine position. Exposure to L2–L4 is not as common as L4–L5 for ALIF procedures partly due to extensive retraction of kidney and renal vessels at L2–L3 along with the peritoneum which may at times lead to superior mesenteric artery thrombosis (20).

L1–L2 procedures are performed via anterolateral extrapleural retroperitoneal approach with patient in right lateral position.

Anterior approach to L2–L5

Position

The patient is positioned supine with upper limbs padded and supported out of the operating field on the sides. To facilitate opening of discs at mid and lower lumbar spine, table may be broken to allow hyperextension or props can be used to accentuate the lordosis.

Incision

A left para-median incision vertically transgressing upwards from the umbilicus is used for exposure of L2–L4. To include L4–L5, the same incision could extend below the umbilicus (Figure 1A,1B). If L4–S1 is to be exposed, a low, transverse, rectus sparing incision could also be used (21). The L3–L4 disc space is thought to be at the level of the umbilicus to help determine the level of the incision. An intraoperative X-ray may guide the incision planning.

Figure 1 Illustration of the anterior abdominal wall and incision planning for L1–L5 ALIF. (A) Left para-median incision cephalad to umbilicus for mid lumbar levels and caudad to umbilicus for low lumbar levels. (B) Vertebral level correlation to the incision. ALIF, anterior lumbar interbody fusion.

Dissection

The left retroperitoneal approach is commonly used for L2–L4 because of the resistant abdominal aorta, avoiding inferior vena cava and liver. The right approach may be used for L5–S1 but usually reserved for revision procedures to avoid the abdominal scaring ipsilaterally. A longitudinal cut is made in the line of skin incision on the anterior rectus sheath exposing the belly of rectus muscle, as illustrated in Figure 2A. The approach is maintained medial to the rectus muscles and the belly is then teased from the transversalis fascia. This approach helps in avoiding the future complication of increased chances of hernia. Caution must be taken at this stage as to not separate the epigastric vessels from the under surface of the rectus muscle. If separated it can cause rectus muscle atrophy. Once the posterior fascia is reached, arcuate ligament is recognized for a portal of entry to the retroperitoneal space as shown in Figure 2B. Figure 2A longitudinal incision over anterior rectus sheath. Figure 2B Identification of the arcuate ligament as a point of entry to the retroperitoneal space.

Figure 2 Illustration of the anterior rectus sheath approach for ALIF. (A) Longitudinal incision over anterior rectus sheath. (B) Identification of the arcuate ligament as a point of entry to the retroperitoneal space, showing the relationship of the rectus abdominis, transversalis fascia, and peritoneum. ALIF, anterior lumbar interbody fusion.

Proceeding caudad to the ligament, retroperitoneal fat is released and the peritoneum is swept cephalad directing the contents medially. The vertebrae or intervertebral disc is visualized by retracting the abdominal viscera and inspecting the psoas muscle, iliac vessels or aorta/inferior vena cava, and ureter is usually medial and is swept along with the peritoneum, as shown in Figure 3 (22).

Figure 3 Identification of psoas muscle and iliac vessels. Ureters should be recognised if exposed.

The retroperitoneum is then retracted to reveal the underlying psoas muscle, fat is dissected from the vessels, and segmental vessels are ligated. After ascertaining a clear view of the intervertebral disc, a rectangular flap is raised of the anterior longitudinal ligament incising the periosteum on the superior and inferior margins of the vertebral bodies. This flap is prepared cautiously as it helps to protect the important adjacent viscera and preserved to the end of procedure which can then be sutured back covering the fusion construct to prevent attrition of reposed viscera and adhesions post operatively.

When the procedure is finished before the removal of instruments and proceeding to the closure, haemostasis is confirmed and fluoroscopy used to confirm implant position.

Vascular considerations

ALIF procedure at L5–S1 may need little or no mobilisation of the abdominal aorta, inferior Vena cava or the common iliac vessels during the exposure but at higher levels they need significant mobilisation. Depending on the anatomical variation, exposure of the L4–L5 disc needs careful mobilisation of the common iliac vessels, as it could be just above the left common iliac artery, between the left common iliac artery and vein or just below the left common iliac vein. As illustrated in Figure 4, access to L4/5 intervertebral disc may require mobilisation of the iliac vessels, and iliolumbar vein; more proximally segmental vessels would require ligation and the great vessels mobilised to access the anterior disc space. Left common iliac vessels pose to be the most vulnerable structure, as they course obliquely across the anterior aspect of the L5 body, traversing variable portions of the L4–L5 and L5–S1 disc spaces in the process. Out of the two common iliac vessels, the left common iliac vein is the most likely vascular structure to be injured during anterior lumbar spinal surgery because of it being most dorsally. Extreme caution is to be used while exposing the L4–L5 disc space at this stage by a routine ligation and division of the ascending iliolumbar vein. This branch acts as a dorsolateral tether to the left common iliac vein, which might lead to a vascular disaster if not released before preparing the disc space (23). Anatomically, two thirds of cases, left iliolumbar vein may present as a single vessel joining common iliac vein 4 cm distal to inferior vena cava, but in one third of cases it may present as double vessel around 3 and 6 cm distal to inferior vena cava. The impending disaster is due to the risk of avulsion of the iliolumbar vein and is simply avoided by routine division which allows for retraction of the left common iliac vein. If neglected, tearing of the iliolumbar vein during mobilisation can result in significant blood loss and with vessel retraction difficulty in repair. Preparing the disc space would need clearing laterally and at this stage use of diathermy is to be avoided due to the sympathetic plexus (13).

Figure 4 The vascular anatomy at L4–L5 emphasizing the reason for highest complication during exposure. Familiarity with the vascular anatomy, positioning of ureters and avoiding sympathetic plexus may avert complications.

Thus, the primary vascular challenge is to the great vessels of the abdomen with exposures of the lower lumbar intervertebral discs during ALIF. The rates of vascular injury may range from 1.9–24% in ALIF, as reported in the literature (21,24). The most common level reported in ALIF with this vascular complication is the L4–L5 intervertebral disc space (25).

Secondarily, the L4 segmental vessels would pose a major bleeding issue if not ligated and released prior to mobilising aortic terminus and terminal inferior vena cava. This will also facilitate the exposure of L4–L5 disc space shifting the major vessels to the right side of the spine.

Few authors advocate the use of sharp/spiked retractors or Steinman pins to be attached to the self-retaining retracting systems. This could increase the chances of vascular injuries as compared to the blunt tipped or reverse lipped retractor blades.

Another vascular challenge apart from the intraoperative haemorrhage seems to be of the acute arterial thrombosis or post-operative thrombotic occlusion of major abdominal veins due to prolonged retraction. Though uncommon, acute arterial thrombosis of left internal iliac artery could result with prolonged retraction and occlusion as grave complication (24). Few surgeons utilise digital pulse oximetry on the left toes to check with preventing over retraction (26). Prolonged retraction of the iliac vein or inferior vena cava could also be a cause for thrombotic occlusion post-operatively which could be detected with doppler (27). Iliac venorrhaphy or successful repair of seemingly minor injuries of the iliac vein intraoperative can result in thrombosis in the postoperative period manifesting as leg symptoms at a later stage. Hence, routine magnetic resonance venography or computed tomographic angiography is deemed necessary in post-operative following iliac veinous repairs (9). The definitive treatment with placement of a vena cava filter is followed after detection of iliac vein thrombosis, as anticoagulants cannot be prescribed in immediate postop.

Visceral injuries

The potential risk for the visceral injuries reported in literature is approximately 5% (28) primarily encompassing the gastrointestinal and genitourinary complications. Injury to peritoneum and in turn causing potential harm to the intestines through inadvertent enterotomy is incidentally low in primary ALIF. Though post-operatively ileus is the most common complication in anterior lumbar spinal surgery.

Practically the injury to ureters is minimal during primary retroperitoneal exposure in ALIF and the best approach would be to retract the ureter medially along with the visceral sac. Skeletonisation of the ureter during the ALIF surgery is not recommended as it may lead to complication as the blood supply is segmental (29).

Sympathetic nerve injuries

The risk for retrograde ejaculation and sympathetic dysfunction accounts for approximately 3% (13). At the lower lumbar spine, mobilising visceral sac en bloc avoids the injury to the sympathetic fibres of the hypogastric plexus which are stuck to the posterior surface of the peritoneum. The risk of injury to sympathetic plexus could further be prevented by minimal use of thermal cautery in preparation of the disc and using scalpel for annulotomy (30).

Abdominal wall complications

The function of muscles of the abdominal wall is maintained with the integrity of the nerves supplying them. It is important to protect the thoraco-abdominal nerves innervating the oblique and rectus abdominis musculature while passing between the internal oblique and transversus abdominis muscle, and likewise preserving the iliohypogastric (superior branch) and ilioinguinal nerves (inferior branch) which innervates the internal oblique and transversus abdominal muscles.

Retroperitoneal lymphocele

Though a rare condition, it needs a mention to complete the list which develops infrequently in association with abdominal aortic surgery as well as lumbar spine surgery (31).

Revision surgeries

The challenge in the revision surgeries is predominantly the scar tissue formation. Revision ALIF surgeries have higher complication rates due to dense retroperitoneal scarring (32). Exposing the anterior surface of the spine or the intervertebral disc space would be difficult owing to the scar tissue from previous surgery between common iliac vein and the aorta (33). There is also a significant danger to the ureter which could be buried in the scar tissue and retraction with instrumentation may lead to stretching or compression and thus lead to its injury.

Recommendations to minimise the vascular and visceral complications

It is advised that peripheral pulses are assessed preoperatively and vascular assessment undertaken with the help of radiological investigations where necessary.

Intraoperatively, retraction to vessels should be minimised in terms of time and distance but should be enough to gain adequate exposure for the preparation of the intervertebral discs. It is important to be precise in the positioning of the retractor blades and observe carefully on removal as the retractor blade tip can catch the posterior aspect of vein and bleeding is usually encountered at the time of release or removal of the blade.

It is pertinent that the vascular injuries are recognised early, especially injury to the venous structures. The damage could be aggravated with frantic suctioning and increasing traction trying to gain better visualisation and access which would result in extension of laceration and thus extra bleeding. It is best to apply direct pressure and release retraction while calling for assistance from a vascular surgeon.

Special attention is called for at the L4–L5 level where the iliolumbar vein should be ligated and released before the preparation of this disc space. If neglected, this vein could be torn and retract at the distal end which renders repair difficult leading to significant haemorrhage.

Involving a vascular surgeon can greatly enhance the safety of retroperitoneal exposure by assisting with mobilisation of the common iliac vessels and aorta, providing access to the disc space while preserving vessel integrity, particularly at the vulnerable L4–L5 level, where the left common iliac vein lies directly anterior to the disc (34). Collaboration between spine and vascular teams has been shown to reduce vascular complication rates, shorten operative times, and facilitate rapid management of unexpected bleeding (13,21). The presence of an access surgeon also enhances intraoperative decision-making, particularly in revision cases or when encountering aberrant vascular anatomy, enables rapid recognition and repair of inadvertent vascular tears. However, this multidisciplinary approach requires close coordination and may limit direct exposure experience for spine surgeons, a factor discussed in the context of surgical training (22). Overall, involving an experienced access surgeon is considered best practice for complex anterior exposures, improving safety and optimising patient outcomes.

It is imperative to assess renal artery anatomy when approaching upper lumbar levels of L2–L4 for ALIF. In approximately 5% of patient an aberrant renal pole artery may be present which can be detected with a CT angiogram along with 3D vascular reconstruction (21).

In patients with atherosclerotic arteries, arterial thrombosis should be an important consideration. Routine monitoring with pulse oximetry of the lower limb on the same side to the site of arterial retraction is advisable.

Post-operative Ileus incidence could be reduced with routine preoperative mechanical bowel preparation and intraoperatively by avoiding nitrous oxide anaesthetic agent along with using an orogastric tube.

An important consideration to reduce the chance of retrograde ejaculation at L4–L5 level, the cautery should not be used around the sympathetic trunk. The disc space clearance should employ blunt dissection and scalpel for annulotomy during preparation of the disc space.

In revision ALIF surgery a precaution to aid identification of the ureter is to administer intravenous methylene blue. This aids protection of the ureter by making it more easily identifiable in the dissection. Delayed images taken during preoperative CT Angiography can also help delineate the course of the ureters, and the potential need for ipsilateral ureteral stent placement.

Principle of venous and arterial repair

Management of venous injury

To control the venous bleeding the patient should be moved to the Trendelenburg position and pressure applied on either side of incidental venotomy. If it is a small tear, topical hemostatic agents including Gelfoam^® (Pfizer, New York, NY), Surgicel^® Fibrillar^TM, Surgiflo^® (Ethicon, Somerville, NJ), and Floseal (Baxter, Deerfield, IL) could be effective. If it persists, attempt to encircle the iliac vein or applying vascular clamps may aggravate the tear and increase the haemorrhage. If clear access is available, it would be best to repair with a continuous 6-0 (nylon/prolene) suture, but if it is less easily accessible, vascular clips placed at perpendicular to the long axis of the tear may be applied in a “railroad track” fashion (Figure 5A,5B). The repair may be complemented with topical haemostatic agents mentioned above or a patch such as tachoseal or hemopatch (Baxter, Deerfield, IL, USA).

Figure 5 Illustration of venous repair techniques during anterior lumbar exposure. (A) Lateral repair of iliac vein with continuous 5-0 suture. (B) Vascular clips placed in “railroad track” fashion for haemostasis and reinforcement of the venotomy repair.

Successful trials of endovascular repair of the left common iliac vein with covered stents also make it a viable methodology (35).

Management of arterial injury

Large vessels should not be retracted using fixed retraction systems and especially if calcification of the vessels is present (36). In the event of haemorrhage from an artery, this may be managed with application of vascular clamps proximal and distal to the arteriotomy and applying traditional lateral suture repair as in managing the venous tear shown in Figure 5A,5B.

Rarely for the arterial thrombotic lesion in atherosclerotic patients, catheter thrombectomy could be needed, sometimes requiring adjunct methods of endarterectomy or bypass.

Conclusions

ALIF surgeries stabilise the spine, thus preventing painful motion, providing indirect neural elements decompression, restoring lordosis and correcting deformity. While this is a powerful technique, it is associated to many serious complications and injury. In depth understanding of anatomical and technical considerations of ALIF is essential to prevent injuries. This study comprehensively reviews the available literature for the considerations for ALIF. Recommendations and guidelines for the indications and complications for ALIF is provided to guide clinicians.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Spine Surgery, for the series “Anterior Lumbar Interbody Fusion—A Definitive Guide for Surgeons”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-132/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-132/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-132/coif). The series “Anterior Lumbar Interbody Fusion—A Definitive Guide for Surgeons” was commissioned by the editorial office without any funding or sponsorship. P.J.R. served as the unpaid Guest Editor of the series and serves as an unpaid Associate Editor of Journal of Spine Surgery from December 2024 to November 2026. R.M. serves as the Editor-in-Chief of Journal of Spine Surgery. Besides, P.J.R. reports consulting fees and research funding from Evolution, Avanos and Lifehealthcare (with no direct relation to the article). R.M. reports speaker and educational engagement in Medacta Int and Australian Biotechnologies, royalties from Stryker Spine and A-Spine, payment or honoraria for manuscript writing from Cerapedics USA, educational support for meeting attendance from Elliquence USA, multiple patents in Jasper MedTech and WAGAR, and shares ownership in Medtronic. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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