Study Design. Retrospective cohort study. Objective. To compare sagittal alignment, reoperation rates, and patient-reported outcomes between anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) in patients ≤50 years. Summary of Background Data. ALIF and TLIF are commonly used lumbar fusion techniques with known differences in alignment restoration and complication profiles. However, comparative outcomes in younger patients, who have greater long-term biomechanical demands, remain poorly defined. Methods. A single-institution retrospective analysis was performed on patients ≤50 years undergoing 1–2 level ALIF (stand-alone or with posterior instrumentation) or TLIF at L4–S1. Radiographic parameters (lumbar lordosis LL, PI–LL mismatch, pelvic tilt PT) were assessed preoperatively and up to 2 years postoperatively. Reoperation rates and indications were recorded, with Kaplan–Meier and Cox regression analyses evaluating reoperation-free survival. Patient-reported outcomes included PROMIS Global Mental Health (GMH) and Physical Health (GPH). Multivariable regression adjusted for age, BMI, CCI, and multilevel fusion. Results. A total of 218 patients were included (ALIF stand-alone: n=60; ALIF+posterior (ALIF +P): n=47; TLIF: n=111). At 2 years, ALIF+P demonstrated greater LL and lower PI–LL mismatch compared to TLIF ( P ≤0.02). Reoperation rates were highest in TLIF (20.7%) versus ALIF stand-alone (10.0%) and ALIF+P (8.5%) ( P =0.03). TLIF was associated with increased reoperation risk compared to ALIF+P (HR 2.13, 95% CI 1.62–2.71). Adjacent segment disease was more common in TLIF ( P =0.040). Early (6-week) GMH and GPH favored TLIF ( P <0.001), whereas final GPH was highest in ALIF+P ( P =0.001). Subsidence rates were similar across groups ( P =0.627). Conclusion. In patients ≤50 years, ALIF with posterior instrumentation provides superior and durable sagittal alignment, lower reoperation rates, and improved long-term physical health compared to TLIF. Although TLIF demonstrates favorable early recovery, circumferential ALIF may offer greater long-term biomechanical and clinical benefit in younger patients.
Sadh et al. (Mon,) studied this question.