Comparative study of multilevel posterior interbody fusion plus anterior longitudinal ligament release versus classic multilevel posterior interbody fusion in the treatment of adult spinal deformities

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Sagittal imbalance and loss of lumbar lordosis are the main drivers of functional disability in adult degenerative scoliosis. The main limitations of the classic posterior lumbar interbody fusion technique are increased risk of neurological injury and suboptimal correction of the segmental lordosis. Here, the authors describe the radiological results of a modified posterior lumbar interbody fusion and compare the results with a historical cohort of patients.


Eighty-two consecutive patients underwent surgical treatment for degenerative scoliosis/kyphosis in a single tertiary referral center for complex spinal surgery. Fifty-five patients were treated using the classic multilevel posterior lumbar interbody fusion (MPLIF) technique and 27 were treated using the modified MPLIF technique to include a release of the anterior longitudinal ligament (ALL) and the annulus. A radiographic review of both series of patients was performed by two independent observers. Functional outcomes were obtained, and patients were registered in the European Spine Tango registry.


The mean L4–5 disc angle increased by 3.14° in the classic MPLIF group and by 12.83° in MPLIF plus ALL and annulus release group. The mean lumbar lordosis increased by 15.23° in the first group and by 25.17° in the second group. The L4–S1 lordosis increased on average by 4.92° in the classic MPLIF group and increased by a mean of 23.7° in the MPLIF plus ALL release group when both L4–5 and L5–S1 segments were addressed. There were significant improvements in the Core Outcome Measures Index and EQ-5D score in both groups (p < 0.001). There were no vascular or neurological injuries observed in either group.


The authors’ preliminary results suggest that more correction can be achieved at the disc level using posterior-based ALL and annulus release in conjunction with posterior lumbar interbody fusion. They demonstrate that ALL and annulus release can be performed safely using a posterior-only approach with minimal risk of vascular injury. However, the authors recommend that this approach should only be used by surgeons with considerable experience in anterior and posterior spinal surgery.

ABBREVIATIONS ALL = anterior longitudinal ligament; COMI = Core Outcome Measures Index; IDA = intradiscal angle; LL = lumbar lordosis; MPLIF = multilevel posterior lumbar interbody fusion; MSA = motion segment angle; NHDU = neurosurgical high dependency unit; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; SVA = sagittal vertical axis; VCR = vertebral column resection.

Article Information

Correspondence Silviu Sabou: Salford Royal Hospital NHS Foundation Trust, Manchester, United Kingdom.

INCLUDE WHEN CITING Published online April 5, 2019; DOI: 10.3171/2019.1.SPINE18754.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Photograph of the custom-made annulotomy knife. Figure is available in color online only.

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    Radiograph demonstrating ALL release performed with a disc spreader.

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    Preoperative radiograph. Figure is available in color online only.

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    Postoperative radiograph. Figure is available in color online only.


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