Anterior Lumbar Interbody Fusion (ALIF)

What is an ALIF?

An ALIF is a spinal operation where the spine is approached from the front rather than from the back. It is performed through the abdomen, usually with the assistance of a vascular surgeon to move the major blood vessels out of the way. The disc is removed and pressure on the nerves can be relieved. A large cage is then placed in the space where the disc was located, and screws are inserted through the cage or a plate and into the spinal bones for extra stability.

What conditions is ALIF used to treat?

ALIF is used to treat a variety of conditions, including:

  1. Painful disc degeneration
  2. Spondylolisthesis
  3. Instability
  4. Spinal deformity or imbalance

What are the advantages of ALIF over other types of lumbar fusion?

ALIF is a very well tolerated procedure, and typically is associated with less pain and a faster recovery than spinal fusion surgery performed from the back of the spine. It allows placement of a much larger cage than other types of spinal fusion, which provides more stability and has a higher chance of fusing solidly. It allows better correction of spinal deformity or imbalance, and this may be associated with better long term outcomes in terms of pain, quality of life, and reduced chance of developing problems at adjacent levels of the spine.

What are the disadvantages of ALIF?

Some patients may not be suitable for ALIF- for example if they have had extensive abdominal surgery in the past, are quite overweight, or have unsuitable vascular anatomy.

What are the risks of surgery?

The risks are the same as for other types of spinal fusion, including bleeding, infection, nerve damage, incontinence, paralysis, blood clots in your legs or lungs, stroke and a very small risk of loss of your leg(s) or death. Because the major blood vessels of the abdomen are nearby, there is a risk of major haemorrhage. In men, there is also a small risk of retrograde ejaculation- where the patient ejaculated into his bladder rather than outside. Hernia is also another potential complication.

What are the implications of surgery?

Most patients are admitted on the same day as their surgery; however, some patients are admitted the day before. Patients admitted the day before surgery include those who: reside in country regions, interstate, or overseas; have complex medical conditions or who take warfarin; require further investigations before their surgery; are first on the operating list for the day. You will be given instructions about when to stop eating and drinking before your admission.
You will be in hospital for between 2 and 4 days after your surgery. You will be given instructions about any physical restrictions that will apply following surgery, and these are summarised later in this section.
Several X-rays of your back will be taken during surgery to make sure that the correct spinal level is being fused, and also to optimise the positioning of the cage and screws. It is critical that you inform us if you are pregnant or think you could possibly be pregnant, as X-rays may be harmful to the unborn child.
There is significant variability between patients in terms of the outcome from surgery, as well as the time taken to recover. You will be given instructions about physical restrictions, as well as your return to work and resumption of recreational activities. You should not drive a motor vehicle or operate heavy machinery until instructed to do so by your neurosurgeon.
You should not sign or witness legal documents until reviewed by your GP post-operatively, as the anaesthetic can sometimes temporarily muddle your thinking.

What are the outcomes of ALIF?

In well-selected patients, the outcomes are generally quite good. 70-80% of patients should obtain a good outcome.

What do I need to do before surgery?

Before surgery it is likely that we will arrange for some prehabilitation with one of our exercise physiologists or physiotherapists. This is to get you into the best shape possible for surgery. If you are overweight, then you should do your best to shed any excess weight. If you smoke, then you should stop. If you take aspirin, warfarin or other anticoagulants, then you should advise the team at Precision Brain Spine and Pain Centre so we can let you know when and how to stop these.

What happens immediately after surgery?

It is usual to feel some pain after surgery, especially at the incision site. Pain medications are usually given to help control the pain. While tingling sensations or numbness is common, and should lessen over time, they should be reported to your neurosurgeon.
Most patients are up and moving around within several hours of surgery. This is encouraged in order to keep circulation normal and avoid blood clot formation in the legs.
You will be able to drink after around 24 hours, depending on how quickly your bowels start contracting and when you start passing wind.
A CT scan will be performed the next day to check the position of the screws and cage.
You will be discharged home when you are comfortable, usually after a short period of inpatient rehabilitation.

What do I need to do after I go home?

We will give you specific instructions. In general, walking for at least an hour in total per day soon after surgery is encouraged. You may require a short period (of around a week) of inpatient rehabilitation, but this is not always necessary. Your pain medications will be gradually reduced. Outpatient rehabilitation with our exercise physiologists and physiotherapists is also frequently recommended.

What else happens after discharge?

You will need to take it easy for 8 weeks, but should walk for at least an hour every day. You should avoid sitting for more than 15-20 minutes continuously during this time.
At 6-8 weeks it is likely that you will be able to return to work on “light duties” and to drive a motor vehicle on short trips. This, and the step-wise progression in your physical activities, will be determined on an individual basis.
Bear in mind that the amount of time it takes to return to normal activities is different for every patient. Discomfort should decrease a little each day. Increases in energy and activity are signs that your post-operative recovery is progressing well. Maintaining a positive attitude, a healthy and well-balanced diet, and ensuring plenty of rest are excellent ways to speed up your recovery.
Signs of infection such as swelling, redness or discharge from the incision, and fever should be brought to the surgeon’s attention immediately.
You will be reviewed after 6-8 weeks by your neurosurgeon. Until then, you should not lift objects weighing more than 2-3kg, and should not engage in bending or twisting movements.
The results of fusion surgery are not as good in patients who smoke or are very overweight. It is therefore important that you give up smoking permanently before your surgery and try to lose as much weight as possible.
You should continue wearing your TED stockings for a couple of weeks after surgery.

What about wound care?

You should keep your wound dry for 3 weeks after surgery- showering is fine as long as you use a waterproof dressing. After 3 weeks, you can take a bath and start hydrotherapy.

Your staples should be removed 12 days postoperatively, and we will give you instructions about how this should be done and who to have them removed by.

What do I need to tell my surgeon about after the operation?

You should notify your neurosurgeon and should also see your GP if you experience any of the following after discharge from hospital:

  • Increasing leg pain, weakness or numbness
  • Worsening back pain
  • Problems passing urine or controlling your bladder or bowels
  • Problems with your walking or balance
  • Fever
  • Swelling, redness, increased temperature or suspected infection of the wound
  • Leakage of fluid from the wound
  • Pain or swelling in your calf muscles (ie. below your knees)
  • Chest pain or shortness of breath
  • Any other concerns