Anterior Lumbar Interbody Fusion Offers Safer Inpatient Profiles But at Greater Cost Compared With Posterolateral Fusion: National Outcomes for Spondylolisthesis From 2016 to 2022.

Abstract

Degenerative lumbar spine disease represents a leading global source of disability, with spondylolisthesis contributing substantially to the burden of low back pain and impaired function. Lumbar fusion remains a commonly performed surgical strategy for degenerative spondylolisthesis, although decompression alone versus decompression with fusion continues to be an area of active debate, particularly in select low-grade cases. This study aimed to compare inpatient complications, discharge disposition, mortality, and costs between anterior lumbar interbody fusion (ALIF) and posterolateral fusion (PLF) for degenerative lumbar spondylolisthesis. The National Inpatient Sample was queried from 2016 to 2022 for elective admissions of adults with a primary diagnosis of lumbar spondylolisthesis undergoing ALIF or PLF. Encounters with both approaches or additional interbody techniques were excluded. Outcomes included perioperative complications, in-hospital mortality, discharge disposition, length of stay, and inflation-adjusted costs. Survey-weighted logistic regression and generalized linear models adjusted for demographics, comorbidities, and hospital factors. Significance was set at the P < 0.05 level. We identified 57,475 weighted admissions: 12,410 ALIF and 45,065 PLF. In adjusted models, PLF was associated with higher odds of transfusion (OR, 2.60; P < 0.001), acute posthemorrhagic anemia (OR, 1.47; P < 0.001), cerebrospinal fluid leak/dural tear (OR, 3.57; P < 0.001), and the adverse-events composite (OR, 1.68; P < 0.001). PLF also demonstrated greater odds of nonroutine discharge (OR, 1.19; P = 0.002). In-hospital mortality was exceedingly rare and not meaningfully different. ALIF was associated with higher mean costs ($43,000 vs. $31,500; P < 0.001) despite shorter length of stay (2.81 vs. 3.31 days; P < 0.001). ALIF for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though at substantially higher inpatient costs. These findings highlight a clinical-economic tradeoff between anterior and PLF strategies at the national level. III.