Anterior lumbar interbody fusion: patient selection and workup

Anterior lumbar interbody fusion (ALIF) is an anterior surgical approach for interbody fusion in the lumbar spine which affords the surgeon unfettered access to the disc space and allows for release of the anterior longitudinal ligament and insertion of a large, lordotic interbody graft. Despite the benefits associated with ALIF when compared with other lumbar interbody fusion techniques, the ALIF approach is associated with a number of unique complications, and certain patient-specific criteria (e.g., vascular anatomy) are important considerations when selecting patients for an ALIF. This review article summarizes the authors’ own patient selection criteria for ALIF and describes the items required for pre-operative workup. Notable criteria to consider when planning an ALIF include: patient age, sex, bone density, body mass index, nicotine usage history, the presence—and severity of—medical comorbidities, anatomy of the distal iliac vein/abdominal aorta/iliac bifurcation/iliocaval confluence, history of prior abdominal surgery/ infection/radiotherapy, surgical goals, operative level and availability of approach co-surgeons. Pre-operative workup for ALIF procedures should at a minimum consist of magnetic resonance imaging of the lumbar spine, standing X-rays of the lumbar spine with flexion/extension views, scoliosis or long-cassette spinal X-rays and a computed tomography of the lumbar spine without contrast as well as a dual-energy X-ray absorptiometry scan.