INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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. LEVEL OF EVIDENCE: III.
Mastrokostas et al. (Tue,) studied this question.