Comparison of rod fracture rates in long spinal deformity constructs after transforaminal versus anterior lumbar interbody fusions: a single-institution analysis

2020 ◽  
Vol 32 (1) ◽  
pp. 42-49
Author(s):  
Owoicho Adogwa ◽  
Jacob M. Buchowski ◽  
Lawrence G. Lenke ◽  
Maksim A. Shlykov ◽  
Mostafa El Dafrawy ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Spinal Deformity ◽  
Interbody Fusion ◽  
Deformity Correction ◽  
Lumbar Interbody Fusion ◽  
Single Institution ◽  
Patient Groups ◽  
Clinical Records ◽  
Rod Fracture

OBJECTIVEPseudarthrosis is a common complication of long-segment fusions after surgery for correction of adult spinal deformity (ASD). Interbody fusions are frequently used at the caudal levels of long-segment spinal deformity constructs as adjuncts for anterior column support. There is a paucity of literature comparing rod fracture rates (proxy for pseudarthrosis) in patients undergoing transforaminal lumbar interbody fusion (TLIF) versus anterior lumbar interbody fusion (ALIF) at the caudal levels of the long spinal deformity construct. In this study the authors sought to compare rod fracture rates in patients undergoing surgery for correction of ASD with TLIF versus ALIF at the caudal levels of long spinal deformity constructs.METHODSWe reviewed clinical records of patients who underwent surgery for correction of ASD between 2008 and 2014 at a single institution. Data including demographics, comorbidities, and indications for surgery, as well as postoperative variables, were collected for each patient. All patients had a minimum 2-year follow-up. Patients were dichotomized into two groups for comparison on the basis of undergoing a TLIF versus an ALIF procedure at the caudal levels of long spinal deformity constructs. The primary outcome of interest was the rate of rod fractures.RESULTSA total of 198 patients (TLIF 133 patients; ALIF 65 patients) underwent a long-segment fusion to the sacrum with iliac fixation. The mean ± standard deviation follow-up period was 62.23 ± 29.26 months. Baseline demographic variables were similar in both patient groups. There were no significant differences between groups in the severity of the baseline sagittal plane deformity (i.e., baseline lumbar-pelvic parameters) or the final deformity correction achieved. Mean total recombinant human bone morphogenetic protein 2 (rhBMP-2) dose for L1–sacrum fusion was significantly higher in the ALIF (100 mg) than in the TLIF (62 mg) group. The overall rod failure rate (cases with rod fracture/total cases) within this case series was 19.19% (38/198); 10.60% (21/198) were unilateral rod fractures and 8.58% (17/198) were bilateral rod fractures. At last clinical follow-up, there were no statistically significant differences in bilateral rod fracture rates between the group of patients who had a TLIF procedure and the group who had an ALIF procedure at the caudal levels of the long spinal deformity constructs (TLIF 10.52% vs ALIF 4.61%, p = 0.11). However, the incidence rate (cases per patient follow-up years) for bilateral rod fractures was significantly higher in the TLIF than in the ALIF cohort (TLIF 2.20% vs ALIF 0.70%, p < 0.0001). The reoperation rate for rod fractures was similar between the patient groups (p = 0.40).CONCLUSIONSAlthough both ALIF and TLIF procedures at the caudal levels of long spinal deformity constructs achieved similar and satisfactory deformity correction, ALIFs were associated with a lower rod fracture incidence rate. There were no differences between groups in the prevalence of rod fracture or revision surgery, however, and both groups had low bilateral rod fracture prevalence and incidence rates. One technique is not clearly superior to the other.

Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion

2021 ◽  
pp. 1-10
Author(s):  
Ki Young Lee ◽  
Jung-Hee Lee ◽  
Kyung-Chung Kang ◽  
Sang-Kyu Im ◽  
Hae Seong Lim ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Interbody Fusion ◽  
Sagittal Alignment ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Lumbar Interbody Fusion ◽  
Patient Factors ◽  
Rod Fracture ◽  
Cobalt Chrome

OBJECTIVERestoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD.METHODSThe authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed.RESULTSThe overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF.CONCLUSIONSGreater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

scholarly journals Efficacy and radiographic analysis of oblique lumbar interbody fusion in treating adult spinal deformity

PLoS ONE ◽  
2021 ◽  
Vol 16 (9) ◽  
pp. e0257316
Author(s):  
Dae-Jean Jo ◽  
Eun-Min Seo
Keyword(s):  
Spinal Deformity ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Lumbar Interbody Fusion ◽  
Spinal Fixation ◽  
Invasive Approach ◽  
Radiographic Parameters ◽  
Oblique Lumbar Interbody Fusion

Adult spinal deformity (ASD) is usually rigid and requires a combined anterior–posterior approach for deformity correction. Anterior lumbar interbody fusion (ALIF) allows direct access to the disc space and placement of a large interbody graft. A larger interbody graft facilitates correction of ASD. However, an anterior approach carries significant risks. Lateral lumbar interbody fusion (LLIF) through a minimally invasive approach has recently been used for ASD. The present study was performed to evaluate the effectiveness of oblique lumbar interbody fusion (OLIF) in the treatment of ASD. We performed a retrospective study utilizing the data of 74 patients with ASD. The inclusion criteria were lumbar coronal Cobb angle > 20°, pelvic incidence (PI)–lumbar lordosis (LL) mismatch > 10°, and minimum follow–up of 2 years. Patients were divided into two groups: ALIF combined with posterior spinal fixation (ALIF+PSF) (n = 38) and OLIF combined with posterior spinal fixation (OLIF+PSF) (n = 36). The perioperative spinal deformity radiographic parameters, complications, and health-related quality of life (HRQoL) outcomes were assessed and compared between the two groups. The preoperative sagittal vertical axis (SVA), LL, PI–LL mismatch, and lumbar Cobb angles were similar between the two groups. Patients in the OLIF+PSF group had a slightly higher mean number of interbody fusion levels than those in the ALIF+PSF group. At the final follow–up, all radiographic parameters and HRQoL scores were similar between the two groups. However, the rates of perioperative complications were higher in the ALIF+PSF than OLIF+PSF group. The ALIF+PSF and OLIF+PSF groups showed similar radiographic and HRQoL outcomes. These observations suggest that OLIF is a safe and reliable surgical treatment option for ASD.

scholarly journals Novel bioabsorbable interbody fusion spacer–assisted fusion for correction of spinal deformity

2003 ◽  
Vol 14 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Rebekah C. Austin ◽  
Charles L. Branch ◽  
Joseph T. Alexander
Keyword(s):  
Spinal Deformity ◽  
Interbody Fusion ◽  
Posterior Lumbar Interbody Fusion ◽  
Low Back ◽  
The Novel ◽  
Lumbar Interbody Fusion ◽  
Fusion Technique ◽  
Scoliotic Deformity ◽  
Radicular Symptoms

Object The authors report the cases of 12 patients with medically refractory mechanical low-back pain and intermittent radicular symptoms in whom radiography demonstrated evidence of multilevel lumbosacral degenerative kyphotic and scoliotic deformity and spondylolisthesis. Methods These patients underwent multilevel posterior lumbar interbody fusion in which Macropore bioabsorbable spacers were placed. Each patient underwent at least 1 year of clinical and radiographic follow up. Conclusions This series illustrates the novel use of bioabsorbable interbody spacers and fusion technique for correction of spinal deformity due to advanced degenerative kyphoscoliosis and spondylolisthesis.

scholarly journals Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

2016 ◽  
Vol 25 (6) ◽  
pp. 697-705 ◽  
Author(s):  
Russell G. Strom ◽  
Junseok Bae ◽  
Jun Mizutani ◽  
Frank Valone ◽  
Christopher P. Ames ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Leg Pain ◽  
Sagittal Imbalance ◽  
Hybrid Strategy ◽  
Lateral Interbody Fusion ◽  
Lateral Interbody

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

Reduced occurrence of primary rod fracture after adult spinal deformity surgery with accessory supplemental rods: retrospective analysis of 114 patients with minimum 2-year follow-up

2021 ◽  
pp. 1-12
Author(s):  
Emily P. Rabinovich ◽  
Thomas J. Buell ◽  
Tony R. Wang ◽  
Christopher I. Shaffrey ◽  
Justin S. Smith
Keyword(s):  
Retrospective Analysis ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Vertical Axis ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Inclusion Criteria ◽  
Sagittal Vertical Axis ◽  
Rod Fracture

OBJECTIVE Rod fracture (RF) after adult spinal deformity (ASD) surgery is reported in approximately 6.8%–33% of patients and is associated with loss of deformity correction and higher reoperation rates. The authors’ objective was to determine the effect of accessory supplemental rod (ASR) placement on postoperative occurrence of primary RF after ASD surgery. METHODS This retrospective analysis examined patients who underwent ASD surgery between 2014 and 2017 by the senior authors. Inclusion criteria were age > 18 years, ≥ 5 instrumented levels including sacropelvic fixation, and diagnosis of ASD, which was defined as the presence of pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°, coronal Cobb angle ≥ 20°, or pelvic incidence to lumbar lordosis mismatch ≥ 10°. The primary focus was patients with a minimum 2-year follow-up. RESULTS Of 148 patients who otherwise met the inclusion criteria, 114 (77.0%) achieved minimum 2-year follow-up and were included (68.4% were women, mean age 67.9 years, average body mass index 30.4 kg/m2). Sixty-two (54.4%) patients were treated with traditional dual-rod construct (DRC), and 52 (45.6%) were treated with ASR. Overall, the mean number of levels fused was 11.7, 79.8% of patients underwent Smith-Petersen osteotomy (SPO), 19.3% underwent pedicle subtraction osteotomy (PSO), and 66.7% underwent transforaminal lumbar interbody fusion (TLIF). Significantly more patients in the DRC cohort underwent SPO (88.7% of the DRC cohort vs 69.2% of the ASR cohort, p = 0.010) and TLIF (77.4% of the DRC cohort vs 53.8% of the ASR cohort, p = 0.0001). Patients treated with ASR had greater baseline sagittal malalignment (12.0 vs 8.6 cm, p = 0.014) than patients treated with DRC, and more patients in the ASR cohort underwent PSO (40.3% vs 1.6%, p < 0.0001). Among the 114 patients who completed follow-up, postoperative occurrence of RF was reported in 16 (14.0%) patients, with mean ± SD time to RF of 27.5 ± 11.8 months. There was significantly greater occurrence of RF among patients who underwent DRC compared with those who underwent ASR (21.0% vs 5.8%, p = 0.012) at comparable mean follow-up (38.4 vs 34.9 months, p = 0.072). Multivariate analysis demonstrated that ASR had a significant protective effect against RF (OR 0.231, 95% CI 0.051–0.770, p = 0.029). CONCLUSIONS This study demonstrated a statistically significant decrease in the occurrence of RF among ASD patients treated with ASR, despite greater baseline deformity and higher rate of PSO. These findings suggest that ASR placement may provide benefit to patients who undergo ASD surgery.

scholarly journals Navigated oblique lumbar interbody fusion for adult spinal deformity

2020 ◽  
Vol 2 (1) ◽  
pp. V7
Author(s):  
Chih-Chang Chang ◽  
Joshua Rivera ◽  
Brenton Pennicooke ◽  
Dean Chou ◽  
Praveen V. Mummaneni
Keyword(s):  
Spinal Deformity ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Computer Assisted ◽  
Lumbar Interbody Fusion ◽  
Disease Entity ◽  
Assisted Navigation ◽  
Reduce Radiation Exposure ◽  
Oblique Lumbar Interbody Fusion

Adult spinal deformity (ASD) is an increasing disease entity as the population ages. An emerging minimally invasive surgery (MIS) option for the treatment of ASD is the oblique lumbar interbody fusion (OLIF), which allows indirect foraminal decompression of stenosis as well as segmental deformity correction (DiGiorgio et al., 2017). The authors utilize computer-assisted navigation with OLIF to reduce radiation exposure and improve time efficiency. The authors present a video of navigated oblique lumbar interbody fusion at L3–5 followed by open posterior screw-rod fixation.The video can be found here: https://youtu.be/zKDT7PhMYf8.

scholarly journals Surgical Outcomes of Multilevel Posterior Lumbar Interbody Fusion versus Lateral Lumbar Interbody Fusion for the Correction of Adult Spinal Deformity: A Comparative Clinical Study

2020 ◽  
Vol 14 (4) ◽  
pp. 421-429 ◽  
Author(s):  
Masayoshi Iwamae ◽  
Akira Matsumura ◽  
Takashi Namikawa ◽  
Minori Kato ◽  
Yusuke Hori ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Spinal Deformity ◽  
Surgical Outcomes ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Posterior Lumbar Interbody Fusion ◽  
Lumbar Interbody Fusion ◽  
Lateral Lumbar Interbody Fusion ◽  
The Mean

Study Design: A retrospective case control study.Purpose: The purpose of this study was to compare the surgical outcomes of multilevel lateral lumbar interbody fusion (LIF) and multilevel posterior lumbar interbody fusion (PLIF) in the surgical treatment of adult spinal deformity (ASD) and to evaluate the sagittal plane correction by combining LIF with posterior-column osteotomy (PCO).Overview of Literature: The surgical outcomes between multilevel LIF and multilevel PLIF in ASD patients remain unclear.Methods: We retrospectively reviewed 31 ASD patients who underwent multilevel LIF combined with PCO (LIF group, n=14) or multilevel PLIF (PLIF group, n=17) and with a minimum 2-year follow-up. In the comparison between LIF and PLIF groups, their mean age at surgery was 69.4 vs. 61.8 years while the mean follow-up period was 29.2 vs. 59.3 months. We evaluated the transition of pelvic incidence–lumbar lordosis (PI–LL) and disc angle (DA) in the LIF group, in fulcrum backward bending (FBB), after LIF and after posterior spinal fusion (PSF) with PCO. The spinopelvic radiographic parameters were compared between LIF and PLIF groups.Results: Compared with the PLIF group, the LIF group had less blood loss and comparable surgical outcomes with respect to radiographic data, health-related quality of life scores and surgical time. In the LIF group, the mean DA and PI–LL were unchanged after LIF (DA, 5.8°; PI–LL, 15°) compared with the values using FBB (DA, 4.3°; PI–LL, 15°) and improved significantly after PSF with PCO (DA, 8.1°; PI–LL, 0°).Conclusions: In the surgical treatment of ASD, multilevel LIF is less invasive than multilevel PLIF and combination of LIF and PCO would be necessary for optimal sagittal correction in patients with rigid deformity.

The minimally invasive interbody selection algorithm for spinal deformity

2021 ◽  
pp. 1-8
Author(s):  
Praveen V. Mummaneni ◽  
Ibrahim Hussain ◽  
Christopher I. Shaffrey ◽  
Robert K. Eastlack ◽  
Gregory M. Mundis ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Spinal Deformity ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Lumbar Interbody Fusion ◽  
Selection Algorithm ◽  
Data Set ◽  
Indirect Decompression ◽  
Segmental Lordosis

OBJECTIVE Minimally invasive surgery (MIS) for spinal deformity uses interbody techniques for correction, indirect decompression, and arthrodesis. Selection criteria for choosing a particular interbody approach are lacking. The authors created the minimally invasive interbody selection algorithm (MIISA) to provide a framework for rational decision-making in MIS for deformity. METHODS A retrospective data set of circumferential MIS (cMIS) for adult spinal deformity (ASD) collected over a 5-year period was analyzed by level in the lumbar spine to identify surgeon preferences and evaluate segmental lordosis outcomes. These data were used to inform a Delphi session of minimally invasive deformity surgeons from which the algorithm was created. The algorithm leads to 1 of 4 interbody approaches: anterior lumbar interbody fusion (ALIF), anterior column release (ACR), lateral lumbar interbody fusion (LLIF), and transforaminal lumbar interbody fusion (TLIF). Preoperative and 2-year postoperative radiographic parameters and clinical outcomes were compared. RESULTS Eleven surgeons completed 100 cMISs for ASD with 338 interbody devices, with a minimum 2-year follow-up. The type of interbody approach used at each level from L1 to S1 was recorded. The MIISA was then created with substantial agreement. The surgeons generally preferred LLIF for L1–2 (91.7%), L2–3 (85.2%), and L3–4 (80.7%). ACR was most commonly performed at L3–4 (8.4%) and L2–3 (6.2%). At L4–5, LLIF (69.5%), TLIF (15.9%), and ALIF (9.8%) were most commonly utilized. TLIF and ALIF were the most selected approaches at L5–S1 (61.4% and 38.6%, respectively). Segmental lordosis at each level varied based on the approach, with greater increases reported using ALIF, especially at L4–5 (9.2°) and L5–S1 (5.3°). A substantial increase in lordosis was achieved with ACR at L2–3 (10.9°) and L3–4 (10.4°). Lateral interbody arthrodesis without the use of an ACR did not generally result in significant lordosis restoration. There were statistically significant improvements in lumbar lordosis (LL), pelvic incidence–LL mismatch, coronal Cobb angle, and Oswestry Disability Index at the 2-year follow-up. CONCLUSIONS The use of the MIISA provides consistent guidance for surgeons who plan to perform MIS for deformity. For L1–4, the surgeons preferred lateral approaches to TLIF and reserved ACR for patients who needed the greatest increase in segmental lordosis. For L4–5, the surgeons’ order of preference was LLIF, TLIF, and ALIF, but TLIF failed to demonstrate any significant lordosis restoration. At L5–S1, the surgical team typically preferred an ALIF when segmental lordosis was desired and preferred a TLIF if preoperative segmental lordosis was adequate.

scholarly journals Metal failure and nonunion at L5-S1 after long instrumented fusion distal to pelvis for adult spinal deformity: Anterior versus transforaminal interbody fusion

2021 ◽  
Vol 29 (3) ◽  
pp. 230949902110542
Author(s):  
Se-Jun Park ◽  
Jin-Sung Park ◽  
Chong-Suh Lee ◽  
Keun-Ho Lee
Keyword(s):  
Failure Rate ◽  
Spinal Deformity ◽  
Revision Surgery ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Anterior Column ◽  
Lumbar Interbody Fusion ◽  
Instrumented Fusion ◽  
Metal Failure

Purpose Pseudoarthrosis and metal failure at L5-S1 following long fusion surgery for adult spinal deformity (ASD) remain major issues. Few studies report on which anterior column support technique is better in terms of achieving fusion and avoiding metal failures. Our study aimed to evaluate the fusion status and metal failure rate at L5-S1 after anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF). Methods The study population included patients aged >50 years who underwent surgery for ASD. Anterior column supports at L5-S1 using ALIF and TLIF were compared with ≥ 2-year follow-up. Fusion status on 2-year computed tomography (CT) scan, metal failure, visual analog scale (VAS), and Oswestry disability index (ODI) were evaluated. Results 98 patients were included in this study (53 ALIF group and 45 TLIF group). We achieved solid fusion on 2-year CT scans in 88.9% and 69.8% patients in the TLIF and ALIF group, respectively. Metal failure developed in nine (17.0%) and six (13.3%) patients in the ALIF and TLIF group, respectively. The most common failure type was unilateral L5-S1 rod fracture (7 and five patients in the ALIF and TLIF group, respectively). Only one patient with bilateral rod fractures in the ALIF group required revision surgery. There were no differences in the VAS and ODI scores at the last follow-up. Conclusions TLIF showed a better fusion rate than ALIF at L5-S1 after long instrumented fusion for ASD. However, the capacity to restore sagittal parameters was greater in the ALIF group. There were no differences between the groups regarding metal failure rate, revision surgery, or clinical outcomes.

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