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Failed anterior lumbar interbody fusion due to incomplete foraminal decompression



Anterior lumbar interbody fusion (ALIF) has gained widespread popularity for spinal disorders requiring fusion. The purpose of this study was to analyze ALIF failures.


The medical records of 223 patients treated with ALIF between January 2007 and June 2008 were retrospectively reviewed. Patients with unfavorable outcomes, including subsequent posterior decompression at the index level or poor outcomes after ALIF were identified based on clinical and radiological findings. The patients were divided into two groups: an unfavorable group and a favorable group. Preoperative clinical and radiological factors for each group were statistically analyzed.


Two hundred of the 223 patients were enrolled in this study. Thirteen (6.5%) of 200 patients resulted in unfavorable outcome. Four patients (2%) of them underwent posterior decompressive surgery. The main cause of unfavorable outcomes was incomplete decompression of the foraminal stenosis. Unfavorable outcomes were obtained in patients with the level of L5-S1 (p = 0.036), higher body mass index (p = 0.048), higher percentage of slippage (p = 0.024), and severe facet arthropathy (p = 0.013). However, there was no difference in preoperative disc height, foraminal size, facet angle, facet tropism, or preoperative visual analog scale for back and leg pain, the Oswestry disability index, symptom duration, and fusion rate between the two groups.


Based on these results, posterior decompression and fusion may be considered for obese patients with the level of L5-S1, high-grade spondylolisthesis, or severe facet arthropathy. On the other hand, ALIF can be used an effective alternative treatment in many spinal disorders requiring fusion.

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The authors thank Jung-In Park, Young-Jin Son, and Bu Hee Kim for their assistance in preparing this manuscript.


The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Correspondence to Yong Ahn.

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This study reviews the clinical results following anterior lumbar interbody fusion (ALIF) in 223 patients who were treated over a 1-year period at a highly specialized spine institute in South Korea. The researchers were interested in modes of ALIF failure where patients did not achieve adequate pain relief, which was the primary goal of the surgery. They identified a total of 13 patients with suboptimal pain relief, and four (2% of the total population) of these underwent a subsequent posterior decompressive surgery. The authors identified obesity, greater degrees of spondylolisthesis, and severe facet arthopathy as predictors of an unfavorable outcome, which is not surprising.

This paper has particular relevance given the resurgence of lumbar interbody distraction techniques to restore interbody height. New minimally invasive procedures such as the XLIF, Axial-Lif, and even unilateral MIS TLIF pre-suppose that vertical distraction is a satisfactory method for addressing nerve root impingement. This issue of “indirect decompression” has now become a topic of great debate with many proponents claiming that the distraction techniques are “always effective.” Common sense suggests that such claims are patently untrue, and that in some cases severe central canal or foraminal stenosis will require the direct removal of osteophytes, disc material, ligamentum, or facet material.

Choi et al. give us a quantitative analysis of what the most powerful interbody technique (i.e., ALIF) can achieve. The results were excellent overall and the benefits of ALIF or any other indirect method for decompression can stand on its own, leaving a small but finite risk of failure and need for direct nerve root decompression. The authors should be complemented on their results and honest reporting of their failures.

Michael Y Wang

Miami, Florida

Sources of support

This study was supported by a grant from the Wooridul Spine Foundation.

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Choi, KC., Ahn, Y., Kang, BU. et al. Failed anterior lumbar interbody fusion due to incomplete foraminal decompression. Acta Neurochir 153, 567–574 (2011).

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  • Failed anterior lumbar interbody fusion
  • Foraminal stenosis
  • Incomplete decompression