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ALIF versus PLIF

AnonymousUserAAnonymousUser Posts: 49,900
edited 06/11/2012 - 8:23 AM in Back Surgery and Neck Surgery
Hi Fellow Spineys,

I wonder if you may be able to shed some light for me.

Which procedure is the more "demanding" and risky?

I have read lots around and to summarise my understanding (which may be all wrong) the PLIF is a technically challanging procedure for the surgeon and risk as major nerves in the way, especially revisions and the ALIF is easier but for major blood vessels which need securing and moving prior to fusion. I read they often use vascular surgeons to complete this.

My surgeon has scared me to death regard sthe ALIF approach and I am curious since this appears on paper to be the safer route. confused. Oh yes.

Please don't tell me it depends on patients and surgeon - I kinda know that. Anyhow, you may have got an opinion from your own docs, please share the pro's and cons.



  • The choice of PLIF or ALIF should depend on the patient. IMO, THE CHOICE SHOULD NOT DEPEND ON THE SURGEON.

    When we were trying to sort through the options of a L2-5 PLIF or L2-5 PLIF and ALIF for my husband, I found that there were doctors who always chose to do it one way or the other, because it was just how they did it. Somewhere on the old site, there was a posting that said, ask the doc if he does them both ways and how he decides to do it one way or another for a particular patient...you. This made a lot of sense to me and it made us more comfortable with our ultimate selection of surgeon and surgical technique. We wanted a surgeon skilled enough and experienced enough to do the surgery the way that would be best for my husband, not the way he liked doing them, felt more comfortable doing them, the only technique he ever mastered, etc.

    Best of luck. I know being a patient is difficult...it is hard work, at best, to sort through all of the options.


  • I'm having an ALIF on Sept 25th. L4-5 L5-S1. My doc said he prefers this way as to the healing process is easier for the patient. He says that the recovery period shouldn't be too long, but then again, I think it also depends on the patient.
    I think most surgeons have their own ways of doing surgeries and for this type, some prefer the front, and others the back. And even some both if need be! It also depends on the patient as to what they need done.
    For me, I didn't have a choice and to tell the truth I really don't care! I just want the surgery for the pain to end!! If I need both, well then do it and just fix me! LOL!
    Get another opinion if you need to and see what they would do. Both surgeries are not fun, I will tell you that. Both have their ups and downs but they are surgery after all.

    Good luck!
  • Hi all

    I am having both surgeries and the reason behind this is that the surgeon prefers to replace S1 via ALIF (less nerve endings/stomach muscles heal better than back muscles) but he is replacing L5 PLIF.

    My understanding is this:

    There are more nerve endings further down the spine and at S1 the risk of damaging these are greater.
    At the front there are large blood vessels, but the split up and go sideways further down, so it is easier to get to S1, but getting to the higher up discs is more risky.

    Also, the less time spent in any area is better, as not as much time stretching the muscles/moving the bowel etc.

    I think it is down to the surgeon, as you wouldn’t want to force a surgeon to operate against his preference and comfort zone.
  • My surgeon does both, he likes ALIF better, because he believes it is an easier recovery for the patient. The nerves are not in the way for ALIF. It does however require a general surgeon to disect through the abdominal contents and secure the great vessels out of the way. My surgeon initially wanted to do this approach for me, but after all my xrays were in, my spondylolisthesis was unstable and he decided it best to go with PLIF so this instability could be dealt with. I think like Terri, that it is best to find someone who is competent/comfortable with both approaches and who will select the one they feel will benefit you the most. I know I was glad he decided on PLIF, because for some reason I found ALIF more frightening.
    If I recall correctly I believe you have a cage in your spinal canal and it would seem PLIF would be necessary to retrieve this (I am no sugeon by far, just makes more sense). PLIF does require retraction of the nerve roots, even more than TLIF. My surgeon used a varied technique on PLIF, called POLAR, posterior oblique lumbar arthrodesis. It is probably closer to TLIF, but not exactly. He entered the spine through the left side. I have a single Bak vista cage placed at an oblique angle to provide anterior support from a posterior approach.

    If you are not happy with your surgeons answers perhaps another opinion is in order, at least to put your mind at ease. Good luck, I am sorry you are having to do this again. Take care, Sue
  • Dear All,

    Thanks for this - all as I thought. My surgeon is great and I have the absolute trust in him - you have to don't you. But as am have a possible non union on S1 which was not addressed at the 1st revision (it was thought to be slowly healing) and I wondering now if he can repair it while I am under the knife this time or if I am likely to have to do it all again.

    I guess I will have to wait and see, just doing the last minute nerves and dread. You know what it is like!

    Anyway, as nicely said, I am not a doctor and best leave that to them. lol.

    I also had unstable spondy so anterior was our of the question and in fact he must have told me about 1 level approach from front - thanks Cali-Sue for reminding me. 2 levels best from back....

    Oh well, in the hands of the Surgeons... 8> >:D<
  • I have to agree with some of the others.
    I mean I have never had a anterior approach, as my dr likes the PLIF. Why you ask??? He doesn't like cutting open all the stomach muscles and moving everything around and out of the way. Going through the back its all right there.

    After having 2 c sections which are completly different of course then a fusion. I do not want anyone touching my belly again. The gas build up, holding the belly while moving. UGGHH
    My muscles in that area are shot.

    I was comfy, more so then some people with a PLIF. I had no stitches or staples which I think makes a huge difference in being comfortable.
    I had staples in my belly and OH MY, yes I am a huge baby with pain :''(

    Thats my story and Im sticking to it :D

  • My Neurosurgeon is doing an ALIF with posterior fixation. She is having a Vascular surgeon do the whole front... Stuff. I am going to meet my Vascular surgeon October 2. My NS said that Anterior only fusions have a higher rate of failure based on my specific issue and age. However, she doesn't think PLIF would be sufficient for me, either. Which is why she is doing cages through the front, with BMP and plastic cages, and screws and rods through the back, for extra support. I also have to wear a brace for 8 weeks. She is very thorough, and I like that. I'm sure the recovery sucks when you're getting surgery through the front and back at the same time... But it's worth it if it will fix the problem. She gave me a flyer with my specific case information and surgical plan to research on Spineuniverse.com. Pretty good site. My NS is awesome. I totally trust her. Hopefully I trust the Vascular surgeon, too! Looking forward to meeting him.
  • Personally I'd rather have a posterior approach. It's so easy to have issues requiring more surgery on your "gut". At least that's what I've seen happen around my neck of the woods.

    For Cervical, well the safest is the anterior approach and the healing time and conerns are less than posterior.

    You've already had it once and you know what to expect.

    Hang in there,

  • But what levels are you having surgery on? 3 level fusion AND 2 disc replacements? As in, 5 level surgery? It's very possible I just don't know how to read very well. Lol.
  • Lo, I wish you well and it sounds like your surgeon is thorough. Is this what they refer to as the 360 - the all around approach?

    Your post doesn't say, are you an unstable spondy?

    I may well miss you b4 you go in, b4 I am back myself so warm wishes and get better soon. >:D<
  • You know, I'm not sure if there is a technical name for it. On my website slip she gave me she wrote "Search for: ALIF with Posterior fixation"

    As far as I know, my only back issues are DDD at L4-L5, and a mild herniation at T11-T12. I don't have any pain from the mild herniation, though. I get pain higher up in my back on the right side whenever I am using my arms to wash dishes, fold laundry, etc... But it's not as bad as the pain from when I sit up straight. If that pain and the leg pain are taken care of by the fusion, then I will be extremely happy!

    I think she said because I'm really young she wanted it to be more secure. I read that a lot of times they do more for the younger patients, because their physical demands normally exceed those of older patients. I am happy she's doing it this way, because the more secure the safer I'll feel. I hope for a nice strong fusion so it will last me til I'm an old lady :) Not sure how realistic that hope is, but Lol. My NS also said bad discs can be genetic and hereditary.. My mom has about 5 or 6 problem discs, and my sister, who's 23, has 2 or so of her own. Hoping the rest of my discs last me til I'm at least a grandmother! :)

    Good luck with your surgery! I hope things work out well for you and you don't require any more revisions! Let us know how you're doing :)
  • I had a TLIF (with anterior incision) my doctor never gave me a choice NOR did he even tell me where my incision would be! I kinda figured it out on my own. My recovery has been amazing!
  • I had an ALIF, because I won't take a blood transfusion,my NS said that the anterior aproach would provide the greatest control over any bleeding issues that may arise.
    And, that there is less chance of nerve damage. I do have a nasty incision, about 11 inches long, (from above the belly button clear down to my you know what. ) And even at 17 weeks out it's still painful, not to mention ugly. I've had a rough time this summer,but I don't think a different approach would have made any difference. Heavens they're cutting your body open, moving some things around, drilling holes in your bones,etc....I have a friend that had a PLIF 3 level and when we compare notes,we both have about the same thing to say, it's painful. And there's no guarantee that either procedure will solve the problems you had to start with. My friend said it took her over a year to feel "normal" again,so I'm not expecting too much at 17 weeks! At this time , I can say that my initial leg pain when sitting/driving is gone, and I think my surgeon will consider that as success. I still have awful pain in my back, hips,along with spasms that go from my shoulder blades to my tail bone.....so I hope time will help in alleving those issues. Anyway.... be prepared , and have some help lined up...with 3 little ones, you'll most definitely need it. I only have one...and man oh man,thank heavens she still takes naps! Keep us posted on what's going on with you....that will help too.
    Take care and I'll be thinking of you!
  • My surgeon opted for an ALIF procedure.. I'm sure it was done to he's preferred method and what needs fusing. The only problem is that I have one 5 inch vertical scar on my stomach :''( and one 2 inch scar on my hip :SS (as they use bone from the iliac crest)
  • How long ago did you have your ALIF?? I was wondering. I'm having an ALIF on Oct 1st for L5-S1. How did you do, any info would be great!!

  • your surgeon should be comfortable with both procedures and choose what is best for you the patient.
    I had the ALIF, 2 level due to spondy and DDD. I was told by my surgeon that this is the best route for what I had due to the fact that he would have the best access to the larger part of the vertabrea. This would allow him to give me instant stability once the plates were in place.
    I really do not believe that one procedure over the other will give you a quicker recovery. Both have their issues and both are major surgery. It was no walk in the park by any means. I started to feel "normal" at 4 months. Now at 6 months my lower back feels great and my stamina is totally back to normal. My biggest issue was with my bowels and that still persists.

    Be sure to research your diagnosis and what the recommended procedure is to repair. Then talk to your doctor about what would work best for you. I got 4 opinions before deciding on a doctor. One only did PLIF's and I was leary of that being the best fix.

    Good luck the decision process was the hardest part of everything for me.
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