Intraoperative Parameters in Anterior Lumbar Interbody Fusion (ALIF) Surgery: A Case Series of 5299 Operated Levels

Intraoperative Parameters in Anterior Lumbar Interbody Fusion (ALIF) Surgery: A Case Series of 5299 Operated Levels | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Intraoperative Parameters in Anterior Lumbar Interbody Fusion (ALIF) Surgery: A Case Series of 5299 Operated Levels Aécio Rubens Dias Pereira Filho, Vinicius Santos Baptista, Matheus Bertolini, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5656382/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2025 Read the published version in Neurosurgical Review → Version 1 posted 10 You are reading this latest preprint version Abstract Context: Anterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure. Objective This study evaluates the operative parameters of this procedure based on a substantial number of cases. Study Design: A retrospective case series. Methods Patient data were retrospectively collected from the database of the Instituto de Acessos à coluna Aécio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed. Results A total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87 ± 12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%). Conclusions ALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature. Anterior Lumbar Interbody Fusion ALIF Complications Spine Surgery Case Series Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Anterior Lumbar Interbody Fusion (ALIF) surgery involves the removal of the intervertebral disc through an abdominal approach. After disc removal, an interbody device is placed in the created space to promote segmental arthrodesis, thereby restoring the biomechanical and structural integrity of the lumbar spine [ 1 , 2 , 3 ]. Initially described in 1932 by Capener, this technique has been employed to treat a wide range of spinal conditions, including disc herniation, disc degeneration, isthmic spondylolisthesis, spinal stenosis, and trauma [ 4 , 5 , 6 , 7 , 8 ]. One of the primary advantages of this procedure is the complete exposure of the intervertebral disc to be treated, allowing its replacement with a larger cage capable of restoring lordosis and sagittal balance [ 9 , 10 , 11 ]. Reports in the literature indicate that this restoration also facilitates indirect decompression of the emerging nerve roots, potentially alleviating referred pain [ 12 , 13 ]. Studies suggest that ALIF surgery offers benefits such as reduced operative times, lower blood loss rates, and shorter hospital stays compared to other lumbar fusion approaches, establishing it as a relevant therapeutic option [ 14 ]. However, the literature reports conflicting intraoperative complication rates, particularly vascular injuries, which appear to be the most common in this procedure. These rates vary widely, ranging from 3–24%, depending on the study [ 15 – 22 ]. The lack of consensus regarding the true incidence of these complications highlights the importance of studies addressing this issue with robust data, contributing to a better understanding of the risks associated with the technique. In this context, the present study retrospectively analyzes the experience of the Instituto de Acessos à coluna Aécio Dias (IAAD) with ALIF surgery performed over 14 years in more than 12,000 procedures, all involving the participation of an access surgeon. Based on this extensive case series, the study aims to elucidate intraoperative complication rates, including vascular injuries, as well as evaluate parameters such as operative times and blood loss volume. By providing data from the largest case series ever reported, this study intends to address gaps in the literature and contribute to a better understanding of the specificities and risks associated with the technique, supporting clinical decision-making and improving surgical outcomes. Methodology Study Design Retrospective observational study of a case series. This study adhered to the recommendations of the Preferred Reporting of Case Series in Surgery (PROCESS) 2020 checklist [ 23 ]. Study Population The study population consisted of adult patients aged over 18 who underwent ALIF surgery. Only cases performed by the institute were included, with the aim of analyzing intraoperative complications and other relevant parameters. This analysis seeks to contribute to the improvement of surgical outcomes, aiming for greater safety and efficacy in the performance of this procedure. Patient Selection The patients in this study were selected from retrospective data collected in the IAAD database, covering the period from April 2019 to December 2023. Since 2019, approximately 5,000 surgeries have been documented in this database, all performed by the team. Although the database was not created exclusively for this research, it was updated in real time during each procedure, ensuring the accuracy and integrity of the information. Within this extensive dataset, a subset corresponds to ALIF surgeries, totaling 3,438 recorded procedures (Fig. 1 ). The use of this database eliminates the need to access physical or digital hospital records, ensuring the security and reliability of the information used in the study. From this database, we collected general demographic information about the patients, as well as detailed perioperative data, including surgical indications, prior spinal surgeries, grafts used, and operative complications, among others. This comprehensive data collection enabled a thorough analysis of surgical outcomes and associated factors. Inclusion Criteria To be included in this study, patients had to meet specific criteria ensuring the relevance and consistency of the analyzed data. Selected patients had to be over 18 years of age and have undergone an ALIF surgery. These procedures must have taken place within the period documented in the IAAD database, spanning from April 2019 to December 2023. Only patients meeting all these criteria were included in the study, ensuring that the analyzed data accurately reflect the circumstances and outcomes of the ALIF procedures performed by the team. Exclusion Criteria Patients who did not meet the inclusion criteria were excluded from this study, ensuring the consistency and accuracy of the analyzed data. Specifically, those who did not undergo an ALIF surgery or whose procedures occurred outside the period recorded in the IAAD database (April 2019 to December 2023) were excluded. Outcomes In this study, the primary outcomes included arterial injuries, venous injuries, injuries to intra- and extraperitoneal organs, as well as damage to the dural sac and nerve roots. Vascular injuries were defined as minor damage to arterial or venous structures, such as partial avulsions or superficial injuries treated with local hemostasis or simple repairs, as well as major injuries requiring more complex interventions. Injuries to intra- and extraperitoneal organs were recorded when direct trauma or associated complications were identified during the procedure. Damage to the dural sac and nerve roots was considered in cases of intraoperatively observed laceration, avulsion, or compression. Secondary outcomes included surgical time, measured from the initial incision to closure, and blood loss, estimated based on the volume of blood lost during the procedure. Data Extraction Data extraction was conducted independently by two researchers, ensuring the accuracy and reliability of the collected information. To maintain data consistency, a double-check process was implemented, in which both researchers compared and validated the extracted information, resolving any discrepancies through consensus. The collected data included the number of patients, gender, age, Body Mass Index (BMI), year of surgery, operated levels, presence of previous spinal surgeries, indication for the procedure, complaints, type of incision, access side (left or right), disc approach, type of ALIF (stand-alone or with posterior supplementation), type of graft, and whether the iliolumbar vein was ligated. This rigorous process aimed to ensure the integrity and quality of the data used for analysis. Surgical Technique The ALIF technique [ 24 ] involves an anterior approach for lumbar interbody fusion, providing direct access to the lumbar spine while minimizing damage to the posterior musculature. The procedure employs a retroperitoneal access route, performed by an access surgeon, to reduce the impact on intra-abdominal and vascular structures, ensuring adequate and safe spinal exposure. Following the initial approach, a complete discectomy is performed, followed by the insertion of an intervertebral implant filled with autologous, allogenic bone graft, or synthetic materials such as bioactive glass. The access surgeon plays a critical technical role in enabling safe and effective access. Statistical Analysis The aim of this study was to describe the incidence of operative morbidities in ALIF surgery without making comparisons between subgroups or other datasets. Descriptive statistics were used as the primary tool, calculating measures of central tendency (mean and median), measures of dispersion (standard deviation and interquartile range), and absolute and relative frequencies for categorical variables. All calculations were performed using R software (version 4.4.2). The results were presented in graphs and tables created in the same software, providing a clear and detailed visualization of the data distributions and the main characteristics of the sample. Considerations The described methodology was carefully designed to ensure the validity and reliability of the results, adhering to best practices in observational research. The rigor in participant selection, data collection, and statistical analysis reflects a commitment to producing robust and reproducible data. Furthermore, the transparency at each stage of the methodological process aims to facilitate study replication and strengthen confidence in the presented conclusions. This approach seeks to provide a significant contribution to the understanding of operative morbidities in ALIF surgery, offering a foundation for future research and advancements in clinical practice. Results Patient Characteristics A total of 3,438 patients were analyzed in this study, with a balanced gender distribution: 48.6% men (1,671) and 51.4% women (1,767). The mean age was 47.87 years (± 12.10), with a median of 46 years and an age range of 18 to 88 years. The majority of patients were overweight or mildly obese, with 56.3% having a BMI between 25 and 30 (Fig. 2 ). Surgeries were performed between 2019 and 2023, with a progressive increase in the number of procedures after 2020, peaking in 2023. Approximately 34.3% of patients had a history of prior spinal surgeries, with arthrodesis and decompression being the most common procedures. Low back pain associated with sciatica was the most frequent complaint (57.4%), followed by isolated low back pain (40.3%) (Fig. 3 ). These findings provide a detailed overview of the demographic and clinical profile of the sample. Further details are available in Table 1 . Table 1 Patient details General characteristics Number of Patients, n 3438 Mean age, y (standard deviation) 47,87 (12,1) Age range, y 18–88 Median age, y 46 Sex (male/female), n 1671/1767 BMI n x < 25 390 25 ≤ x < 30 1935 30 ≤ x < 35 842 35 ≤ x 40 57 Year of Surgery n 2019 186 2020 57 2021 1096 2022 998 2023 1101 Previous surgery n Arthrodesis 440 Decompression 220 Block 219 Endoscopy 113 LLIF/TLIF/PLIF 38 Corpectomy 3 None 2260 Other 145 Complaint n Only lumbar pain 1384 Only sciatic pain 51 Lumbar + Sciatic pain 1975 Not reported 28 Features of the Procedure Of the 3,438 patients analyzed, the majority (54.9%) underwent surgery at a single level, while 36.9% had two levels operated on, and only 8.3% required interventions at three or more levels, totaling 5,299 operated levels. The L5-S1 and L4-L5 levels were the most frequently addressed, accounting for 37.5% and 15.9% of the surgeries, respectively (Fig. 4 ). The primary indication for ALIF surgery was Degenerative Disc Disease (DDD), representing 33.7% of cases, followed by disc herniation (24.7%), pseudoarthrosis (21.1%), and spondylolisthesis (11.4%). Other indications, such as sagittal imbalance, adjacent level disease, and cage migration, were less frequent (Fig. 5 ). Regarding surgical techniques, most skin incisions were longitudinal midline (84.9%), with Pfannenstiel (7.9%) and transverse incisions (7.2%) used less frequently. Stand-Alone ALIF was performed in 52% of cases, while the remaining 48% involved posterior supplementation. Grafts were used in all patients undergoing ALIF surgery. Among the graft types, 3,060 (89%) were allografts, 177 (5.2%) were autografts, and 201 (5.8%) were bioactive glass. These results provide a comprehensive overview of the technical approaches and clinical indications observed, as detailed in Table 2 . Table 2 Perioperative details Level n L5-S1 1290 L4-L5 545 L4-L5-S1 1105 L3-L4 48 L3-L4-L5 150 L3-L4-L5-S1 228 L2-L3 3 L2-L3-L4 13 L2-L3-L4-L5 31 L2-L3-L4-L5-S1 25 Total operated levels 5299 Indication n Degenerative Disc Disease 1160 Pseudarthrosis 725 Spondylolisthesis 390 Herniated Disc 850 Adjacent Level Disease 78 Sagittal Imbalance 82 Cage Migration 28 Discitis or Cage Infection 23 Other 102 Incision n Longitudinal 2919 Transverse 247 Pfannestiel 272 ALIF type n Stand-Alone 1786 With posterior supplementation 1652 Graft type n Heterologous 3060 Autologous 177 Bioactive Glass 201 Description: none Operative Results In this study, all identified vascular injuries were minor, requiring neither transfusions nor complex repairs. The incidence of arterial injuries was 0.29% (10 cases), with the majority occurring in the left common iliac artery (90%) and only one injury recorded in the abdominal aorta. Venous injuries were more frequent, accounting for 2.96% of cases (102 occurrences), with the most common being in the left common iliac vein (71.6%), followed by the right common iliac vein (13.7%) and the inferior vena cava (14.7%). A total of 112 vascular injuries were documented, 59 of which were treated with direct sutures and 53 with hemostatic barriers. No injuries were recorded in the epigastric vessels. Among other complications, two dural sac injuries (0.06%), one intra- or extraperitoneal structure injury (ureter, 0.03%), and three nerve root injuries (0.09%) were reported. The ureteral injury was repaired with sutures and a double-J stent, with spontaneous resolution of hematuria within seven days. Dural sac injuries were treated with sealant and autologous fat grafts without postoperative complications. Nerve root injuries were deemed minor and required no interventions. No deaths related to intraoperative complications occurred. The approach between the iliac vessels to the intervertebral disc was the most commonly used, followed by the left lateral and combined approaches. Ligation of the iliolumbar vein was necessary in fewer than 10% of cases to facilitate the retraction of major vessels [ 25 ]. Surgery duration varied widely, with most procedures completed within 120 minutes. Blood loss was generally low, with fewer than 1% of patients experiencing losses exceeding 500 mL, and only one exceptional case of 1,000 mL, which was successfully managed without subsequent complications. These findings are detailed further in Table 3 . Table 3 Intraoperative details Bleeding n x < 150 mL 2864 150 ≤ x < 250 mL 341 250 ≤ x 500 mL 34 Operative time n x < 60 502 60 ≤ x < 90 1177 90 ≤ x < 120 844 x ≥ 120 915 Intraoperative injury n Epigastric injury (%) 0 (0) Arterial injury (%) 10 (0,29) Venous injury (%) 102 (2,96) Peritoneal structures injury (%) 1 (0,02) Nerve root involvement (%) 3 (0,08) Dural sac injury (%) 2 (0,06) Injury repair n Suture 60 Barrier hemostatic 53 Iliolumbar ligature n Yes 332 No 3106 Disc approach n Approach between iliac vessels 1453 Left lateral 769 Combined 1216 Description: none Discussion Vascular Injury The arterial injuries observed in this study, with an incidence of 0.29%, align with the available literature, which reports rates ranging from 0.4–4.3% [ 26 – 31 ]. While this variation is influenced by differences in team experience and sample sizes, our study, with a substantial number of cases, provides a more representative estimate of the surgical reality of ALIF. The predominance of injuries to the left common iliac artery reflects its critical location in the surgical approach, emphasizing the need for heightened attention in this area. These results underscore the importance of experienced surgical teams and advanced techniques, factors that may have contributed to the low complication rate observed. The incidence of venous injuries (2.96%) is consistent with reported values in the literature, which range from 0.8–4.3% [ 27 – 34 ]. The higher risk of injury to the left common iliac vein compared to other vascular structures is directly related to its proximity to the surgical field and the manipulation required during spinal exposure. These findings highlight the critical role of the access surgeon in minimizing vascular damage, as careful surgical approaches and the proper management of minor complications are key to achieving favorable procedural outcomes. Thus, the low morbidity observed in our study reflects the importance of meticulous surgical planning and the integration of multidisciplinary teams. Other Injuries In a retrospective review of general complications in 60 patients undergoing ALIF, Rajaraman et al. (1999) [ 35 ] reported no cases of dural sac or nerve root injuries, a finding also observed in other smaller studies [ 36 , 37 ]. In contrast, our experience identified two dural sac injuries (0.06%) and three nerve root injuries (0.09%), all without significant clinical impact. Nerve root injuries were classified as minor and required no repairs, while dural sac injuries were effectively treated with sealant and autologous grafts. According to a meta-analysis by Phan et al. (2015) [ 38 ], the ALIF technique demonstrates low rates of dural sac injury, attributed to reduced manipulation of posterior spinal structures compared to other fusion approaches [ 39 , 40 , 41 , 42 ]. The large number of cases analyzed in our study complements this evidence, providing more accurate and clinically relevant rates for this type of complication. Intra-abdominal organ injuries, such as bowel injuries, are associated with significant morbidity and mortality, as reviewed by Siasios et al. (2018) [ 43 ]. However, meticulous surgical planning can prevent these events [ 44 ]. In ALIF surgeries, these complications are rare, as reported by Amaral et al. (2017) [ 45 ], who documented no visceral injuries in their study. In the present study, only one ureteral injury was recorded (0.03%), with no injuries to other intra- or extraperitoneal organs, corroborating the rarity of such complications in the literature [ 37 , 38 ]. Although ureteral injuries are described as uncommon in ALIF surgery [ 27 ], case studies highlight effective approaches for managing this complication when it occurs [ 46 , 47 ]. Momin et al. (2020) [ 31 ] also reported only one ureteral injury among 652 patients, suggesting that risk factors such as prior abdominal surgeries may increase the likelihood of these events. Nonetheless, the rates found in this study and in the literature remain extremely low, reinforcing the safety of the procedure when performed by an experienced team. Operative Time In a series of 137 patients undergoing ALIF for various indications, Phan et al. (2017) [ 48 ] reported an average operative time of 103.92 minutes ± 33.56. Lindado et al. (2022) [ 37 ], in a retrospective study of 337 patients, documented an average time of 121 minutes among the 147 patients for whom this data was recorded. Other studies indicate average durations close to 3 hours [ 49 , 50 , 51 ], depending on case complexity and team experience. In the present study, more than half of the surgeries (58.79%) were performed within 60 to 120 minutes, with the 60 to 90-minute range being the most frequent (34.24%). These data suggest that the duration of surgeries in this study was consistently lower than the 145.61-minute average reported in previous reviews [ 16 ]. The observed efficiency may be attributed to the use of well-standardized techniques and the experience of surgical teams, including the presence of an access surgeon, who can optimize the time required for the exposure and handling of anatomical structures. These findings reinforce ALIF as a relatively quick procedure when performed by highly skilled teams. Bleeding Bleeding rates in ALIF, as observed in this study, were predominantly low, with 83.3% of patients experiencing blood loss below 150 mL and only 0.99% recording losses exceeding 500 mL. The maximum value of 1,000 mL was associated with an inferior vena cava injury, which was promptly managed without further complications. These findings align with the literature, which identifies ALIF as an approach generally associated with lower bleeding rates compared to other fusion techniques [ 12 , 42 , 51 , 52 ]. Previous studies emphasize that vascular complications are key contributors to increased bleeding rates. Quraishi et al. (2013) [ 36 ] highlighted that venous injuries can significantly elevate blood loss (p > 0.0005). However, studies such as Mobbs et al. (2016) [ 17 ], involving 227 patients treated by a combined team of access and spinal surgeons, reported an average bleeding rate of only 103 mL. Conversely, broader reviews, such as the one previously described [ 16 ], report higher averages, such as 272.75 mL across 517 evaluated patients. These variations reflect differences in surgical technique, intraoperative management, and complication incidence. In the present study, the low bleeding rate can be attributed to the team's experience and the use of practices prioritizing vascular safety, underscoring the importance of surgical planning and a multidisciplinary approach. Indications, Surgical Strategies and Vascular Approaches The indications for the procedure were broad, reflecting the study's objective of mapping the prevalence and diversity of conditions leading to the selection of ALIF as a surgical intervention. Based on our clinical experience, we observed that indications have a greater impact on postoperative morbidity than on intraoperative outcomes, supporting the decision not to impose restrictions on the indications included in this study. Regarding skin incisions, we adopted different strategies for male and female patients. In male patients, longitudinal incisions were prioritized regardless of the operated level. In female patients, transverse or Pfannenstiel incisions were preferred at the L5-S1 level, with a particular preference for Pfannenstiel incisions in cases with high pelvic incidence. This approach aimed to balance surgical exposure with a more satisfactory aesthetic outcome. Vascular approaches varied according to the operated level. At the L5-S1 level, access between the iliac vessels was used, while for other levels, the left lateral approach was chosen to avoid manipulation of the inferior vena cava, a more delicate structure located on the right. For cases involving multiple levels, including L5-S1, a combined approach was employed, integrating access between the iliac vessels and the left side. Iliolumbar vein ligation was performed primarily at the L4-L5 level, accounting for approximately 5% of cases, to optimize intervertebral disc exposure [ 25 ]. These surgical strategies were grounded in technical principles that prioritize patient safety and procedural efficacy, highlighting the importance of individualized planning to minimize complications and optimize outcomes. Strengths and Limitations This study presents several strengths that underscore its relevance in analyzing intraoperative morbidities associated with ALIF surgery. The large number of cases analyzed is a significant highlight, enabling greater statistical precision and a detailed assessment of complications and outcomes. Additionally, the study was conducted in a center with highly standardized procedures, including the participation of an access surgeon, which enhances the quality of the data and its applicability to similar settings that follow comparable protocols. On the other hand, the retrospective nature of the study limits the control of confounding variables and restricts the analysis to information previously recorded in the database. These factors may influence the scope of the conclusions. Another consideration is that the results reflect the experience of a single specialized center, which may limit their applicability to institutions with lower case volumes or different surgical practices. Despite these limitations, the data presented contribute to the literature by offering a broad perspective on the intraoperative complications associated with ALIF. Prospective and multicenter studies could complement these findings, validating the results in diverse contexts and introducing new perspectives on factors influencing surgical outcomes. Conclusion ALIF surgery has proven to be a safe and effective procedure with low intraoperative morbidity, particularly when performed by an integrated team comprising spinal and access surgeons. The results of this study confirm the low incidence of severe complications, such as vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and intra- or extraperitoneal organ injuries (0.03%). Furthermore, the observed surgical times and blood loss volumes were consistent with literature standards, reinforcing the efficiency of the technique. Declarations Disclosure The authors declare that they have no conflicts of interest in relation to the content of this manuscript. Ethics declaration This study was approved by the Prevent Senior Research Ethics Committee (No. 83838524.6.0000.8114), ensuring compliance with ethical standards for research involving human subjects. Informed consent was waived due to the retrospective nature of the study and the use of anonymized data. Description Body Mass Index = BMI. Lateral Lumbar Interbody Fusion = LLIF. Transforaminal Lumbar Interbody Fusion = TLIF. Posterior Lumbar Interbody Fusion = PLIF. Funding No funds, grants, or other support was received. Author Contribution F.C.F.C., M.K.U., N.R.C.A., A.C.B., A.V.D., A.R.D.P.F., and V.M.B. performed material preparation, data collection, and analysis. V.S.B. and M.G.V.B.M. wrote the first draft of the manuscript and conducted the data and statistical analyses. The manuscript was critically revised by F.C.F.C., M.K.U., N.R.C.A., A.C.B., A.V.D., A.R.D.P.F., and V.M.B. Administrative support and supervision were provided by A.R.D.P.F. and V.M.B. All authors contributed to the study conception and design, reviewed the manuscript, and approved the final version. References Kapustka B, Kiwic G, Chodakowski Paweł, Miodoński J, Tomasz Wysokiński M, Łączyński K, Paruzel, Kotas A (2020) Anterior lumbar interbody fusion (ALIF): biometrical results and own experiences. 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Eur Spine J 12(1):48–54. https://doi.org/10.1007/s00586-002-0460-4 Momin AA, Barksdale EM, Lone Z, Enders JJ, Nowacki AS, Winkelman RD, Krantz M, Hardy DM, Steinmetz MP (2020) Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study. Spine J 20(7):1037–1043. https://doi.org/10.1016/j.spinee.2020.03.009 Kaiser MG, Haid RW, Subach BR, Miller JS, Smith CD, Rodts GE (2002) Comparison of the Mini-open versus Laparoscopic Approach for Anterior Lumbar Interbody Fusion: A Retrospective Review. Neurosurgery 51(1):97–105. https://doi.org/10.1097/00006123-200207000-00015 Lee S-H, Choi W-G, Lim S-R, Kang H-Y, Shin S-W (2004) Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis. Spine J 4(6):644–649. https://doi.org/10.1016/j.spinee.2004.04.012 Pelletier Y, Lareyre F, Cointat C, Raffort J (2021) Management of Vascular Complications during Anterior Lumbar Spinal Surgery Using Mini-Open Retroperitoneal Approach. Ann Vasc Surg 74:475–488. https://doi.org/10.1016/j.avsg.2021.01.077 Rajaraman V, Vingan R, Roth P, Heary RF, Conklin L, Jacobs GB (1999) Visceral and vascular complications resulting from anterior lumbar interbody fusion. J Neurosurgery: Spine 91(1):60–64. https://doi.org/10.3171/spi.1999.91.1.0060 Quraishi NA, Konig M, Booker SJ, Shafafy M, Boszczyk BM, Grevitt MP, Mehdian H, Webb JK (2013) Access related complications in anterior lumbar surgery performed by spinal surgeons. European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 22(1):S16–20. https://doi.org/10.1007/s00586-012-2616-1 Lindado CA, Devia DA, Gutiérrez S, Patiño SI, Ocampo MI, Berbeo ME, Diaz RC (2022) Intraoperative Complications of Anterior Lumbar Interbody Fusion: A 5-Year Experience of a Group of Spine Surgeons Performing Their Own Approaches. Int J Spine Surg 8299. https://doi.org/10.14444/8299 Phan K, Thayaparan GK, Mobbs RJ (2015) Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion – systematic review and meta-analysis. Br J Neurosurg 29(5):705–711. https://doi.org/10.3109/02688697.2015.1036838 Harmon PH (1963) Anterior excision and vertebral body fusion operation for intervertebral disk syndromes of the lower lumbar spine: three-to five-year results in 244 cases. Clin Orthop Relat Res 26:107–127. https://pubmed.ncbi.nlm.nih.gov/13952859/ Gumbs AA, Bloom ND, Bitan FD, Hanan SH (2007) Open anterior approaches for lumbar spine procedures. Am J Surg 194(1):98–102. https://doi.org/10.1016/j.amjsurg.2006.08.085 Mummaneni PV, Haid RW, Rodts GE (2004) Lumbar interbody fusion: state-of-the-art technical advances. J Neurosurg 1(1):24–30. https://doi.org/10.3171/spi.2004.1.1.0024 Kim J-S, Kim D-H, Lee S-H, Park C-K, Hwang JY, Cheh G, Choi Y, Kang B-U, Lee H (2010) Comparison Study of the Instrumented Circumferential Fusion with Instrumented Anterior Lumbar Interbody Fusion as a Surgical Procedure for Adult Low-Grade Isthmic Spondylolisthesis. 73(5):565–571. https://doi.org/10.1016/j.wneu.2010.02.057 Ioannis Siasios, Vakharia K, Khan A, Meyers J, Yavorek S, Pollina J, Dimopoulos VG (2018) Bowel injury in lumbar spine surgery: a review of the literature. J Spine Surg 4(1):130–137. https://doi.org/10.21037/jss.2018.03.10 Bianchi C, Ballard JL, Abou-Zamzam AM, Teruya TH, Abu-Assal ML (2003) Anterior Retroperitoneal Lumbosacral Spine Exposure: Operative Technique and Results. Ann Vasc Surg 17(2):137–142. https://doi.org/10.1007/s10016-001-0396-x Amaral R, Ferreira R, Marchi L, Jensen R, Nogueira-Neto J, Pimenta L (2017) Stand-alone anterior lumbar interbody fusion – complications and perioperative results. Revista Brasileira de Ortop (English Edition) 52(5):569–574. https://doi.org/10.1016/j.rboe.2017.08.016 Migliorini F, de Maria N, Tafuri A, Porcaro AB, Rubilotta E, Balzarro M, Lorenzo-Gomez M-F, Antonelli A (2023) Late diagnosis of ureteral injury from anterior lumbar spine interbody fusion surgery: Case report and literature review. Urologia 90(3):579–583. https://doi.org/10.1177/03915603211030230 Leroy H-A, De Buck P, Marcq G, Assaker R (2023) How to manage a ureteral injury after anterior lumbar spine interbody fusion surgery. Neurochirurgie 69(6):101503. https://doi.org/10.1016/j.neuchi.2023.101503 Phan K, Rogers P, Rao PJ, Mobbs RJ (2017) Influence of Obesity on Complications, Clinical Outcome, and Subsidence After Anterior Lumbar Interbody Fusion (ALIF): Prospective Observational Study. World Neurosurg 107:334–341. https://doi.org/10.1016/j.wneu.2017.08.014 Xi Z, Burch S, Mummaneni PV, Chang C-C, Ruan H, Eichler C, Chou D (2020) Supine anterior lumbar interbody fusion versus lateral position oblique lumbar interbody fusion at L5-S1: A comparison of two approaches to the lumbosacral junction. J Clin Neurosci 82:134–140. https://doi.org/10.1016/j.jocn.2020.10.043 Platz U, Halm H, Thomsen B, Pecsi F, Köszegvary M, Bürger NK, Berlin C, Quante M (2021) Anterior Lumbar Interbody Fusion (ALIF) or Transforaminal Lumbar Interbody Fusion (TLIF) for Fusion Surgery in L5/S1 – What Is the Best Way to Restore a physiological Alignment? Z Fur Orthopadie Und Unfallchirurgie 160(06):646–656. https://doi.org/10.1055/a-1560-3106 Dorward IG, Lenke LG, Bridwell KH, OʼLeary PT, Stoker GE, Pahys JM, Kang MM, Sides BA, Koester LA (2013) Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis. Spine 38(12):E755–762. https://doi.org/10.1097/BRS.0b013e31828d6ca3 Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M (2012) Stand-alone Anterior Versus Anteroposterior Lumbar Interbody Single-level Fusion After a Mean Follow-up of 41 Months. J Spin Disord Tech 25(7):362–369. https://doi.org/10.1097/bsd.0b013e3182263d91 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2025 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 22 Feb, 2025 Reviews received at journal 22 Feb, 2025 Reviews received at journal 10 Feb, 2025 Reviewers agreed at journal 06 Feb, 2025 Reviewers agreed at journal 03 Feb, 2025 Reviewers agreed at journal 02 Feb, 2025 Reviewers invited by journal 06 Jan, 2025 Editor assigned by journal 06 Jan, 2025 Submission checks completed at journal 18 Dec, 2024 First submitted to journal 16 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5656382","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":391867664,"identity":"e4679e30-864a-477e-9a32-ea8b004d7a41","order_by":0,"name":"Aécio Rubens Dias Pereira 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Paulo","correspondingAuthor":false,"prefix":"","firstName":"Vinicius","middleName":"Santos","lastName":"Baptista","suffix":""},{"id":391867666,"identity":"f06e650a-a070-46d1-8b1f-4d20efb09944","order_by":2,"name":"Matheus Bertolini","email":"","orcid":"","institution":"Universidade Federal de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Matheus","middleName":"","lastName":"Bertolini","suffix":""},{"id":391867667,"identity":"6323d1d3-e1f9-4778-b7c1-e4451dcf61de","order_by":3,"name":"Francisco Cialdine Frota Carneiro Júnior","email":"","orcid":"","institution":"Instituto de Acessos à coluna Aécio Dias","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"Cialdine Frota Carneiro","lastName":"Júnior","suffix":""},{"id":391867668,"identity":"aa4a1a5e-dd47-4ba5-b50d-3076ad099c17","order_by":4,"name":"Milton Kiyonory Uehara","email":"","orcid":"","institution":"Instituto de Acessos à coluna Aécio 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Dias","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"Vinhal","lastName":"Desideri","suffix":""},{"id":391867672,"identity":"c0d31640-a438-4f19-8a1a-a85be94c94f3","order_by":8,"name":"Vinicius de Meldau Benites","email":"","orcid":"","institution":"Universidade Federal de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Vinicius","middleName":"de Meldau","lastName":"Benites","suffix":""}],"badges":[],"createdAt":"2024-12-16 19:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5656382/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5656382/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-025-03496-z","type":"published","date":"2025-03-26T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72289689,"identity":"2514544f-45a9-4924-8b9a-0f1f6f0525d5","added_by":"auto","created_at":"2024-12-24 17:21:15","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":122876,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatient Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription: \u003c/strong\u003eNone.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/5482423d8d9bfab7997671dd.jpg"},{"id":72289697,"identity":"fb970970-632e-4f43-a64e-0466533c93ec","added_by":"auto","created_at":"2024-12-24 17:21:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17199,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBody Mass Index (BMI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription: \u003c/strong\u003eBMI distribution by range.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/3806507adc8ce70b62f08893.jpg"},{"id":72289674,"identity":"f29dbe11-ce9c-474e-be69-bcb7f4f27b70","added_by":"auto","created_at":"2024-12-24 17:21:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":17399,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComplaints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription: \u003c/strong\u003eNone.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/9d499932087b54e3ba1c23d7.png"},{"id":72291575,"identity":"251d6a2f-be33-4f16-b526-00395a83959b","added_by":"auto","created_at":"2024-12-24 17:29:14","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20656,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOperated Levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription: \u003c/strong\u003eNumber and types of levels operated in our series.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/5bf0df5d7a9f777902eed131.jpg"},{"id":72289688,"identity":"4ebd00e0-707f-45bc-8fd5-592be1f8373a","added_by":"auto","created_at":"2024-12-24 17:21:15","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":28396,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIndications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription: \u003c/strong\u003eDistribution of indications in our sample.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/4ed26d00504000459e155eff.jpg"},{"id":79604828,"identity":"2ac8d8c0-86a8-4e5b-9579-0a53eca6dd5b","added_by":"auto","created_at":"2025-03-31 16:07:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1226188,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5656382/v1/0778b1e8-94da-4960-ab25-c60e7b989d4f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraoperative Parameters in Anterior Lumbar Interbody Fusion (ALIF) Surgery: A Case Series of 5299 Operated Levels","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnterior Lumbar Interbody Fusion (ALIF) surgery involves the removal of the intervertebral disc through an abdominal approach. After disc removal, an interbody device is placed in the created space to promote segmental arthrodesis, thereby restoring the biomechanical and structural integrity of the lumbar spine [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Initially described in 1932 by Capener, this technique has been employed to treat a wide range of spinal conditions, including disc herniation, disc degeneration, isthmic spondylolisthesis, spinal stenosis, and trauma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the primary advantages of this procedure is the complete exposure of the intervertebral disc to be treated, allowing its replacement with a larger cage capable of restoring lordosis and sagittal balance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Reports in the literature indicate that this restoration also facilitates indirect decompression of the emerging nerve roots, potentially alleviating referred pain [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies suggest that ALIF surgery offers benefits such as reduced operative times, lower blood loss rates, and shorter hospital stays compared to other lumbar fusion approaches, establishing it as a relevant therapeutic option [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the literature reports conflicting intraoperative complication rates, particularly vascular injuries, which appear to be the most common in this procedure. These rates vary widely, ranging from 3\u0026ndash;24%, depending on the study [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The lack of consensus regarding the true incidence of these complications highlights the importance of studies addressing this issue with robust data, contributing to a better understanding of the risks associated with the technique.\u003c/p\u003e \u003cp\u003e In this context, the present study retrospectively analyzes the experience of the Instituto de Acessos \u0026agrave; coluna A\u0026eacute;cio Dias (IAAD) with ALIF surgery performed over 14 years in more than 12,000 procedures, all involving the participation of an access surgeon. Based on this extensive case series, the study aims to elucidate intraoperative complication rates, including vascular injuries, as well as evaluate parameters such as operative times and blood loss volume. By providing data from the largest case series ever reported, this study intends to address gaps in the literature and contribute to a better understanding of the specificities and risks associated with the technique, supporting clinical decision-making and improving surgical outcomes.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eRetrospective observational study of a case series. This study adhered to the recommendations of the Preferred Reporting of Case Series in Surgery (PROCESS) 2020 checklist [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of adult patients aged over 18 who underwent ALIF surgery. Only cases performed by the institute were included, with the aim of analyzing intraoperative complications and other relevant parameters. This analysis seeks to contribute to the improvement of surgical outcomes, aiming for greater safety and efficacy in the performance of this procedure.\u003c/p\u003e\n\u003ch3\u003ePatient Selection\u003c/h3\u003e\n\u003cp\u003eThe patients in this study were selected from retrospective data collected in the IAAD database, covering the period from April 2019 to December 2023. Since 2019, approximately 5,000 surgeries have been documented in this database, all performed by the team. Although the database was not created exclusively for this research, it was updated in real time during each procedure, ensuring the accuracy and integrity of the information. Within this extensive dataset, a subset corresponds to ALIF surgeries, totaling 3,438 recorded procedures (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The use of this database eliminates the need to access physical or digital hospital records, ensuring the security and reliability of the information used in the study. From this database, we collected general demographic information about the patients, as well as detailed perioperative data, including surgical indications, prior spinal surgeries, grafts used, and operative complications, among others. This comprehensive data collection enabled a thorough analysis of surgical outcomes and associated factors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003eTo be included in this study, patients had to meet specific criteria ensuring the relevance and consistency of the analyzed data. Selected patients had to be over 18 years of age and have undergone an ALIF surgery. These procedures must have taken place within the period documented in the IAAD database, spanning from April 2019 to December 2023. Only patients meeting all these criteria were included in the study, ensuring that the analyzed data accurately reflect the circumstances and outcomes of the ALIF procedures performed by the team.\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003ePatients who did not meet the inclusion criteria were excluded from this study, ensuring the consistency and accuracy of the analyzed data. Specifically, those who did not undergo an ALIF surgery or whose procedures occurred outside the period recorded in the IAAD database (April 2019 to December 2023) were excluded.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eIn this study, the primary outcomes included arterial injuries, venous injuries, injuries to intra- and extraperitoneal organs, as well as damage to the dural sac and nerve roots. Vascular injuries were defined as minor damage to arterial or venous structures, such as partial avulsions or superficial injuries treated with local hemostasis or simple repairs, as well as major injuries requiring more complex interventions. Injuries to intra- and extraperitoneal organs were recorded when direct trauma or associated complications were identified during the procedure. Damage to the dural sac and nerve roots was considered in cases of intraoperatively observed laceration, avulsion, or compression. Secondary outcomes included surgical time, measured from the initial incision to closure, and blood loss, estimated based on the volume of blood lost during the procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eData extraction was conducted independently by two researchers, ensuring the accuracy and reliability of the collected information. To maintain data consistency, a double-check process was implemented, in which both researchers compared and validated the extracted information, resolving any discrepancies through consensus. The collected data included the number of patients, gender, age, Body Mass Index (BMI), year of surgery, operated levels, presence of previous spinal surgeries, indication for the procedure, complaints, type of incision, access side (left or right), disc approach, type of ALIF (stand-alone or with posterior supplementation), type of graft, and whether the iliolumbar vein was ligated. This rigorous process aimed to ensure the integrity and quality of the data used for analysis.\u003c/p\u003e\n\u003ch3\u003eSurgical Technique\u003c/h3\u003e\n\u003cp\u003eThe ALIF technique [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] involves an anterior approach for lumbar interbody fusion, providing direct access to the lumbar spine while minimizing damage to the posterior musculature. The procedure employs a retroperitoneal access route, performed by an access surgeon, to reduce the impact on intra-abdominal and vascular structures, ensuring adequate and safe spinal exposure. Following the initial approach, a complete discectomy is performed, followed by the insertion of an intervertebral implant filled with autologous, allogenic bone graft, or synthetic materials such as bioactive glass. The access surgeon plays a critical technical role in enabling safe and effective access.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe aim of this study was to describe the incidence of operative morbidities in ALIF surgery without making comparisons between subgroups or other datasets. Descriptive statistics were used as the primary tool, calculating measures of central tendency (mean and median), measures of dispersion (standard deviation and interquartile range), and absolute and relative frequencies for categorical variables. All calculations were performed using R software (version 4.4.2). The results were presented in graphs and tables created in the same software, providing a clear and detailed visualization of the data distributions and the main characteristics of the sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConsiderations\u003c/h2\u003e \u003cp\u003eThe described methodology was carefully designed to ensure the validity and reliability of the results, adhering to best practices in observational research. The rigor in participant selection, data collection, and statistical analysis reflects a commitment to producing robust and reproducible data. Furthermore, the transparency at each stage of the methodological process aims to facilitate study replication and strengthen confidence in the presented conclusions. This approach seeks to provide a significant contribution to the understanding of operative morbidities in ALIF surgery, offering a foundation for future research and advancements in clinical practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 3,438 patients were analyzed in this study, with a balanced gender distribution: 48.6% men (1,671) and 51.4% women (1,767). The mean age was 47.87 years (\u0026plusmn;\u0026thinsp;12.10), with a median of 46 years and an age range of 18 to 88 years. The majority of patients were overweight or mildly obese, with 56.3% having a BMI between 25 and 30 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Surgeries were performed between 2019 and 2023, with a progressive increase in the number of procedures after 2020, peaking in 2023. Approximately 34.3% of patients had a history of prior spinal surgeries, with arthrodesis and decompression being the most common procedures. Low back pain associated with sciatica was the most frequent complaint (57.4%), followed by isolated low back pain (40.3%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These findings provide a detailed overview of the demographic and clinical profile of the sample. Further details are available in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Patients, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3438\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age, y (standard deviation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47,87 (12,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge range, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian age, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female), n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1671/1767\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026lt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1935\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e842\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYear of Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthrodesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e440\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecompression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLIF/TLIF/PLIF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorpectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplaint\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly lumbar pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1384\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly sciatic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar\u0026thinsp;+\u0026thinsp;Sciatic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1975\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFeatures of the Procedure\u003c/h2\u003e \u003cp\u003eOf the 3,438 patients analyzed, the majority (54.9%) underwent surgery at a single level, while 36.9% had two levels operated on, and only 8.3% required interventions at three or more levels, totaling 5,299 operated levels. The L5-S1 and L4-L5 levels were the most frequently addressed, accounting for 37.5% and 15.9% of the surgeries, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe primary indication for ALIF surgery was Degenerative Disc Disease (DDD), representing 33.7% of cases, followed by disc herniation (24.7%), pseudoarthrosis (21.1%), and spondylolisthesis (11.4%). Other indications, such as sagittal imbalance, adjacent level disease, and cage migration, were less frequent (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRegarding surgical techniques, most skin incisions were longitudinal midline (84.9%), with Pfannenstiel (7.9%) and transverse incisions (7.2%) used less frequently. Stand-Alone ALIF was performed in 52% of cases, while the remaining 48% involved posterior supplementation.\u003c/p\u003e \u003cp\u003eGrafts were used in all patients undergoing ALIF surgery. Among the graft types, 3,060 (89%) were allografts, 177 (5.2%) were autografts, and 201 (5.8%) were bioactive glass. These results provide a comprehensive overview of the technical approaches and clinical indications observed, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL4-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL4-L5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3-L4-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3-L4-L5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L3-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L3-L4-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L3-L4-L5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operated levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegenerative Disc Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudarthrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpondylolisthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHerniated Disc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjacent Level Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSagittal Imbalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCage Migration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscitis or Cage Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLongitudinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2919\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfannestiel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALIF type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStand-Alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1786\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith posterior supplementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGraft type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterologous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutologous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBioactive Glass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eDescription: none\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOperative Results\u003c/h2\u003e \u003cp\u003eIn this study, all identified vascular injuries were minor, requiring neither transfusions nor complex repairs. The incidence of arterial injuries was 0.29% (10 cases), with the majority occurring in the left common iliac artery (90%) and only one injury recorded in the abdominal aorta. Venous injuries were more frequent, accounting for 2.96% of cases (102 occurrences), with the most common being in the left common iliac vein (71.6%), followed by the right common iliac vein (13.7%) and the inferior vena cava (14.7%). A total of 112 vascular injuries were documented, 59 of which were treated with direct sutures and 53 with hemostatic barriers. No injuries were recorded in the epigastric vessels.\u003c/p\u003e \u003cp\u003eAmong other complications, two dural sac injuries (0.06%), one intra- or extraperitoneal structure injury (ureter, 0.03%), and three nerve root injuries (0.09%) were reported. The ureteral injury was repaired with sutures and a double-J stent, with spontaneous resolution of hematuria within seven days. Dural sac injuries were treated with sealant and autologous fat grafts without postoperative complications. Nerve root injuries were deemed minor and required no interventions. No deaths related to intraoperative complications occurred.\u003c/p\u003e \u003cp\u003eThe approach between the iliac vessels to the intervertebral disc was the most commonly used, followed by the left lateral and combined approaches. Ligation of the iliolumbar vein was necessary in fewer than 10% of cases to facilitate the retraction of major vessels [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Surgery duration varied widely, with most procedures completed within 120 minutes. Blood loss was generally low, with fewer than 1% of patients experiencing losses exceeding 500 mL, and only one exceptional case of 1,000 mL, which was successfully managed without subsequent complications. These findings are detailed further in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026lt;\u0026thinsp;150 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2864\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e150\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;250 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e250\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;500 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026gt;\u0026thinsp;500 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperative time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026lt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e502\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90\u0026thinsp;\u0026le;\u0026thinsp;x\u0026thinsp;\u0026lt;\u0026thinsp;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e844\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026thinsp;\u0026ge;\u0026thinsp;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpigastric injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0,29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (2,96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeritoneal structures injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNerve root involvement (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0,08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDural sac injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0,06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury repair\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarrier hemostatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIliolumbar ligature\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisc approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach between iliac vessels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eDescription: none\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eVascular Injury\u003c/h2\u003e \u003cp\u003eThe arterial injuries observed in this study, with an incidence of 0.29%, align with the available literature, which reports rates ranging from 0.4\u0026ndash;4.3% [\u003cspan additionalcitationids=\"CR27 CR28 CR29 CR30\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. While this variation is influenced by differences in team experience and sample sizes, our study, with a substantial number of cases, provides a more representative estimate of the surgical reality of ALIF. The predominance of injuries to the left common iliac artery reflects its critical location in the surgical approach, emphasizing the need for heightened attention in this area. These results underscore the importance of experienced surgical teams and advanced techniques, factors that may have contributed to the low complication rate observed.\u003c/p\u003e \u003cp\u003eThe incidence of venous injuries (2.96%) is consistent with reported values in the literature, which range from 0.8\u0026ndash;4.3% [\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The higher risk of injury to the left common iliac vein compared to other vascular structures is directly related to its proximity to the surgical field and the manipulation required during spinal exposure. These findings highlight the critical role of the access surgeon in minimizing vascular damage, as careful surgical approaches and the proper management of minor complications are key to achieving favorable procedural outcomes. Thus, the low morbidity observed in our study reflects the importance of meticulous surgical planning and the integration of multidisciplinary teams.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eOther Injuries\u003c/h2\u003e \u003cp\u003eIn a retrospective review of general complications in 60 patients undergoing ALIF, Rajaraman et al. (1999) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] reported no cases of dural sac or nerve root injuries, a finding also observed in other smaller studies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In contrast, our experience identified two dural sac injuries (0.06%) and three nerve root injuries (0.09%), all without significant clinical impact. Nerve root injuries were classified as minor and required no repairs, while dural sac injuries were effectively treated with sealant and autologous grafts. According to a meta-analysis by Phan et al. (2015) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], the ALIF technique demonstrates low rates of dural sac injury, attributed to reduced manipulation of posterior spinal structures compared to other fusion approaches [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The large number of cases analyzed in our study complements this evidence, providing more accurate and clinically relevant rates for this type of complication.\u003c/p\u003e \u003cp\u003eIntra-abdominal organ injuries, such as bowel injuries, are associated with significant morbidity and mortality, as reviewed by Siasios et al. (2018) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, meticulous surgical planning can prevent these events [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In ALIF surgeries, these complications are rare, as reported by Amaral et al. (2017) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], who documented no visceral injuries in their study. In the present study, only one ureteral injury was recorded (0.03%), with no injuries to other intra- or extraperitoneal organs, corroborating the rarity of such complications in the literature [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Although ureteral injuries are described as uncommon in ALIF surgery [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], case studies highlight effective approaches for managing this complication when it occurs [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Momin et al. (2020) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] also reported only one ureteral injury among 652 patients, suggesting that risk factors such as prior abdominal surgeries may increase the likelihood of these events. Nonetheless, the rates found in this study and in the literature remain extremely low, reinforcing the safety of the procedure when performed by an experienced team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eOperative Time\u003c/h2\u003e \u003cp\u003eIn a series of 137 patients undergoing ALIF for various indications, Phan et al. (2017) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] reported an average operative time of 103.92 minutes\u0026thinsp;\u0026plusmn;\u0026thinsp;33.56. Lindado et al. (2022) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], in a retrospective study of 337 patients, documented an average time of 121 minutes among the 147 patients for whom this data was recorded. Other studies indicate average durations close to 3 hours [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], depending on case complexity and team experience.\u003c/p\u003e \u003cp\u003eIn the present study, more than half of the surgeries (58.79%) were performed within 60 to 120 minutes, with the 60 to 90-minute range being the most frequent (34.24%). These data suggest that the duration of surgeries in this study was consistently lower than the 145.61-minute average reported in previous reviews [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The observed efficiency may be attributed to the use of well-standardized techniques and the experience of surgical teams, including the presence of an access surgeon, who can optimize the time required for the exposure and handling of anatomical structures. These findings reinforce ALIF as a relatively quick procedure when performed by highly skilled teams.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBleeding\u003c/h2\u003e \u003cp\u003eBleeding rates in ALIF, as observed in this study, were predominantly low, with 83.3% of patients experiencing blood loss below 150 mL and only 0.99% recording losses exceeding 500 mL. The maximum value of 1,000 mL was associated with an inferior vena cava injury, which was promptly managed without further complications. These findings align with the literature, which identifies ALIF as an approach generally associated with lower bleeding rates compared to other fusion techniques [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies emphasize that vascular complications are key contributors to increased bleeding rates. Quraishi et al. (2013) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] highlighted that venous injuries can significantly elevate blood loss (p\u0026thinsp;\u0026gt;\u0026thinsp;0.0005). However, studies such as Mobbs et al. (2016) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], involving 227 patients treated by a combined team of access and spinal surgeons, reported an average bleeding rate of only 103 mL. Conversely, broader reviews, such as the one previously described [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], report higher averages, such as 272.75 mL across 517 evaluated patients. These variations reflect differences in surgical technique, intraoperative management, and complication incidence.\u003c/p\u003e \u003cp\u003eIn the present study, the low bleeding rate can be attributed to the team's experience and the use of practices prioritizing vascular safety, underscoring the importance of surgical planning and a multidisciplinary approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eIndications, Surgical Strategies and Vascular Approaches\u003c/h2\u003e \u003cp\u003eThe indications for the procedure were broad, reflecting the study's objective of mapping the prevalence and diversity of conditions leading to the selection of ALIF as a surgical intervention. Based on our clinical experience, we observed that indications have a greater impact on postoperative morbidity than on intraoperative outcomes, supporting the decision not to impose restrictions on the indications included in this study.\u003c/p\u003e \u003cp\u003eRegarding skin incisions, we adopted different strategies for male and female patients. In male patients, longitudinal incisions were prioritized regardless of the operated level. In female patients, transverse or Pfannenstiel incisions were preferred at the L5-S1 level, with a particular preference for Pfannenstiel incisions in cases with high pelvic incidence. This approach aimed to balance surgical exposure with a more satisfactory aesthetic outcome.\u003c/p\u003e \u003cp\u003eVascular approaches varied according to the operated level. At the L5-S1 level, access between the iliac vessels was used, while for other levels, the left lateral approach was chosen to avoid manipulation of the inferior vena cava, a more delicate structure located on the right. For cases involving multiple levels, including L5-S1, a combined approach was employed, integrating access between the iliac vessels and the left side. Iliolumbar vein ligation was performed primarily at the L4-L5 level, accounting for approximately 5% of cases, to optimize intervertebral disc exposure [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese surgical strategies were grounded in technical principles that prioritize patient safety and procedural efficacy, highlighting the importance of individualized planning to minimize complications and optimize outcomes.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study presents several strengths that underscore its relevance in analyzing intraoperative morbidities associated with ALIF surgery. The large number of cases analyzed is a significant highlight, enabling greater statistical precision and a detailed assessment of complications and outcomes. Additionally, the study was conducted in a center with highly standardized procedures, including the participation of an access surgeon, which enhances the quality of the data and its applicability to similar settings that follow comparable protocols.\u003c/p\u003e \u003cp\u003eOn the other hand, the retrospective nature of the study limits the control of confounding variables and restricts the analysis to information previously recorded in the database. These factors may influence the scope of the conclusions. Another consideration is that the results reflect the experience of a single specialized center, which may limit their applicability to institutions with lower case volumes or different surgical practices.\u003c/p\u003e \u003cp\u003eDespite these limitations, the data presented contribute to the literature by offering a broad perspective on the intraoperative complications associated with ALIF. Prospective and multicenter studies could complement these findings, validating the results in diverse contexts and introducing new perspectives on factors influencing surgical outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eALIF surgery has proven to be a safe and effective procedure with low intraoperative morbidity, particularly when performed by an integrated team comprising spinal and access surgeons. The results of this study confirm the low incidence of severe complications, such as vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and intra- or extraperitoneal organ injuries (0.03%). Furthermore, the observed surgical times and blood loss volumes were consistent with literature standards, reinforcing the efficiency of the technique.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest in relation to the content of this manuscript.\u003c/p\u003e\u003ch2\u003eEthics declaration\u003c/h2\u003e \u003cp\u003eThis study was approved by the Prevent Senior Research Ethics Committee (No. 83838524.6.0000.8114), ensuring compliance with ethical standards for research involving human subjects. Informed consent was waived due to the retrospective nature of the study and the use of anonymized data.\u003c/p\u003e\u003ch2\u003eDescription\u003c/h2\u003e \u003cp\u003eBody Mass Index\u0026thinsp;=\u0026thinsp;BMI. Lateral Lumbar Interbody Fusion\u0026thinsp;=\u0026thinsp;LLIF. Transforaminal Lumbar Interbody Fusion\u0026thinsp;=\u0026thinsp;TLIF. Posterior Lumbar Interbody Fusion\u0026thinsp;=\u0026thinsp;PLIF.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eF.C.F.C., M.K.U., N.R.C.A., A.C.B., A.V.D., A.R.D.P.F., and V.M.B. performed material preparation, data collection, and analysis. V.S.B. and M.G.V.B.M. wrote the first draft of the manuscript and conducted the data and statistical analyses. The manuscript was critically revised by F.C.F.C., M.K.U., N.R.C.A., A.C.B., A.V.D., A.R.D.P.F., and V.M.B. Administrative support and supervision were provided by A.R.D.P.F. and V.M.B. All authors contributed to the study conception and design, reviewed the manuscript, and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKapustka B, Kiwic G, Chodakowski Paweł, Miodoński J, Tomasz Wysokiński M, Łączyński K, Paruzel, Kotas A (2020) Anterior lumbar interbody fusion (ALIF): biometrical results and own experiences. Wiesław Marcol 43(2):687\u0026ndash;693. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10143-019-01108-1\u003c/span\u003e\u003cspan address=\"10.1007/s10143-019-01108-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKunal Varshneya, Medress ZA, Jensen M, Azad TD, Rodrigues A, Stienen MN, Desai A, Ratliff JK, Anand Veeravagu (2019) Trends in Anterior Lumbar Interbody Fusion in the United States. 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Spine 38(12):E755\u0026ndash;762. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BRS.0b013e31828d6ca3\u003c/span\u003e\u003cspan address=\"10.1097/BRS.0b013e31828d6ca3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M (2012) Stand-alone Anterior Versus Anteroposterior Lumbar Interbody Single-level Fusion After a Mean Follow-up of 41 Months. J Spin Disord Tech 25(7):362\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/bsd.0b013e3182263d91\u003c/span\u003e\u003cspan address=\"10.1097/bsd.0b013e3182263d91\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Anterior Lumbar Interbody Fusion, ALIF, Complications, Spine Surgery, Case Series","lastPublishedDoi":"10.21203/rs.3.rs-5656382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5656382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eContext:\u003c/h2\u003e \u003cp\u003eAnterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study evaluates the operative parameters of this procedure based on a substantial number of cases.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e \u003cp\u003eA retrospective case series.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatient data were retrospectively collected from the database of the Instituto de Acessos \u0026agrave; coluna A\u0026eacute;cio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature.\u003c/p\u003e","manuscriptTitle":"Intraoperative Parameters in Anterior Lumbar Interbody Fusion (ALIF) Surgery: A Case Series of 5299 Operated Levels","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 17:21:08","doi":"10.21203/rs.3.rs-5656382/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-22T15:09:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-22T14:45:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-11T03:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211875111027721728121614913256364418491","date":"2025-02-07T04:36:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194252224129114290922906131209328358103","date":"2025-02-03T21:18:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277244634285313988332305732209085462315","date":"2025-02-02T08:09:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-06T21:27:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-06T21:26:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-18T11:34:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-12-16T19:26:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"00e79389-e09b-49c0-ad4d-51459d5c618f","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:59:55+00:00","versionOfRecord":{"articleIdentity":"rs-5656382","link":"https://doi.org/10.1007/s10143-025-03496-z","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2025-03-26 15:57:15","publishedOnDateReadable":"March 26th, 2025"},"versionCreatedAt":"2024-12-24 17:21:08","video":"","vorDoi":"10.1007/s10143-025-03496-z","vorDoiUrl":"https://doi.org/10.1007/s10143-025-03496-z","workflowStages":[]},"version":"v1","identity":"rs-5656382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5656382","identity":"rs-5656382","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}