Comparison and clinical applicability analysis of all-posterior, combined anterior-posterior, and combined lateral-posterior approaches in adult spinal deformities: a narrative review

Introduction

The world’s population is living longer, thus, there is an increasing number of individuals experiencing degenerative scoliosis-associated symptoms during their sixth and seventh decades of life (1,2). Sagittal imbalance is associated with pain and disability which results from an accumulation of progressive, degenerative changes that may cause neural compression or debilitating low back pain due to curve progression or loss of sagittal alignment; therefore, correcting sagittal parameters and decompressing affected neural components are one of the main goals of adult spinal deformity (ASD) surgery (3,4). Degenerative lumbar disease accounts for some of the lowest quality of life across all medical specialties, causing greater disability than organ transplantation, cardiac diseases, and some cancers (5). Although ASD surgery leads to significant improvement in quality of life, perioperative morbidity remains high, with blood transfusions (27.0%), myocardial infarction (8.4%), wound complication (2.4%), deep vein thrombosis (DVT)/pulmonary embolism (PE) (1.8%), and urinary tract infection (1.6%) constituting the most common subgroups of morbidity (6,7). Various surgical procedures can be utilized to correct ASD including fusion and osteotomies. Many surgical approaches and fusion techniques have been created with the effort of minimizing complications and improving outcomes. Most variations in approach can be separated into one of the following three categories: traditional all-posterior (P), combined anterior-posterior (AP), or combined lateral-posterior (LP). The two most common approaches are the staged combined AP approach and the traditional P approach (8). Although there are few articles that compare the outcomes between AP and P approaches, there are even fewer that compare these two with that of the LP approach. Many of these articles focus primarily on surgical efficacy, radiographic alignment goals, and complication profile; therefore, discussions are lacking on a reproducible framework that can be used to help choose an adequate approach based on patient history, surgical history, radiographic measurements, and operative goals of the patient (4,6,8-14). Hence, the purpose of this review is to objectively compare the three approaches, their clinical applications, and clearly list the strengths and limitations for each approach. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-5/rc).

Methods

A literature search through PubMed was performed and included articles that were published between February 1981 to February 2025. The search terms that were used can be found in Table 1. The search focused on ASD and those articles that compared the P, combined AP, and LP approaches.

Defining the three approaches to ASD surgery

The P approach

The P approach has remained the tried-and-true approach for ASD, providing the ability to fix an extensive deformity with a single approach through use of segmental pedicle screw instrumentation, osteotomies, and posterior interbody fusions [posterior lumbar interbody fusion and transforaminal lumbar interbody fusion (TLIF)] to achieve the desired spine deformity correction (Figure 1) (15). While the AP approach is often more successful in treating spinal deformity, it is associated with increased risks in frail patients due to a second induction of general anesthesia, increased operating time, and blood loss (9,16). Therefore, for patients who cannot tolerate those surgeries, the P approach can still achieve impressive results (17). Even in severe cases of spinal deformity, pedicle subtraction osteotomies or multi-level posterior column osteotomies can provide appropriate correction of sagittal alignment (18-20).

Figure 1 Preoperative and postoperative lateral radiographs demonstrating correction of severe sagittal imbalance through an all-posterior approach. (A) Preoperative lateral standing radiograph with prior posterior instrumentation spanning from L4–S1. (B) One-year postoperative lateral standing radiograph depicting an all-posterior spinal fusion from T4-pelvis with removal of prior instrumentation, an L4 pedicle subtraction osteotomy, use of satellite rods spanning from L3–L5, and S2A1 pelvic screws. The use of hooks at the upper level with anatomic placement of pedicle screws is designed to minimize adjacent segment disease (images courtesy of N.A.P.).

Combined AP approach

The addition of the anterior approach in ASD has brought several mechanical advantages to the posterior approach, which has caused the combined procedure to gain popularity (17,21). Historically, the pure anterior approach has most often been used at the L5–S1 level (22). When combined with posterior fusion, greater sagittal correction can be achieved (Figure 2) (8). An important mechanical benefit of the anterior approach is that it allows for direct removal of anterior osteophytes and bony bridges which can assist in realigning the lumbosacral curve (23). The anterior approach, or anterior lumbar interbody fusion (ALIF), also allows for a better restoration of lumbar lordosis by using a large footprint, lordotic interbody cage, which maximizes rigidity and thereby minimizes posterior implant loosening and failure when paired with a posterior approach due to its high fusion rate and large footprint area (24). As the name suggests, the anterior approach requires a direct line of sight to the anterior spine, which involves traversing the peritoneal cavity. This anatomy may be an unfamiliar territory for spine surgeons; therefore, many surgeons prefer the assistance of an “access surgeon”, which is usually a general or vascular surgeon, who will mobilize and retract the peritoneum and vascular structures allowing wide access to the anterior spinal column (25). This also minimizes medico-legal liability.

Figure 2 Preoperative and postoperative lateral radiographs demonstrating correction of severe sagittal imbalance through an anterior-posterior approach. (A) Lateral standing radiograph displaying preoperative sagittal alignment with lumbar kyphosis. (B) Postoperative lateral standing radiograph showing correction of sagittal alignment via an L3–S1 anterior lumbar interbody fusion, L1–L3 anterior annulus releases, and a T10-pelvis posterior instrumented fusion (images courtesy of N.A.P.).

Combined LP approach

Like the anterior approach, the lateral approach when combined with the posterior approach can provide significant deformity correction and higher fusion rates when compared to the P approach (26). The lateral approach has many mechanical advantages, similar to the anterior approach, including the ability to insert a large lordotic interbody cage (Figure 3) (27). The lateral and oblique lateral approaches utilize a retroperitoneal approach accessing the spine either trans- or anterior to the psoas muscle (28). Due to its minimally invasive nature and lateral entrance angle, it does not require the assistance of an access surgeon. This retroperitoneal corridor avoids key anatomical structures, such as anterior vasculature (aorta and inferior vena cava) (29).

Figure 3 Preoperative and postoperative imaging depicting the use of the combined LP approach in achieving correction of alignment and addressing degenerative discs. (A) Sagittal CT scan demonstrating intradiscal VP at disc spaces L1–L2 and L2–L3. The arrows indicate intradiscal VP. (B) Preoperative lateral standing radiograph with previous posterior spinal fusion at L3–L5 and an ALIF L5–S1. (C) Postoperative lateral standing radiograph showing an LLIF at L1–L2 and L2–L3, a posterior column osteotomy at L4–L5, and T10-pelvis posterior spinal fusion. ALIF, anterior lumbar interbody fusion; CT, computed tomography; LLIF, lateral lumbar interbody fusion; LP, lateral-posterior; VP, vacuum phenomenon.

The trans-psoas approach requires dilation and retraction of the psoas to achieve exposure of the disc space. To minimize neuropraxia of the lumbar plexus (especially the femoral nerve), neuromonitoring is essential (30). Alternatively, the oblique lateral approach, as seen in oblique lateral interbody fusion (OLIF), takes an approach anterior to the psoas which reduces the risk of psoas and neurologic injury, although it does bring the major vascular structures into the approach (31,32). A study by Teli et al. found that anterior-to-psoas approaches combined with long posterior instrumentation led to lower rates of pseudoarthrosis when compared to similar cases that underwent P or the combined transpsoas-posterior approach (10).

Discussion: strengths, weaknesses, and clinical applications

The surgical management of ASD is complex and requires careful consideration of the strengths and limitations of each approach to optimize patient outcomes. When determining the relative benefits and drawbacks of each surgical technique mentioned previously, it is important to note that there is no technique that is superior to the others. The decision to use a singular or combined approach or the angle by which one accesses the spine, such as ALIF vs. lateral lumbar interbody fusion (LLIF), is entirely dependent on the patient’s medical history, symptomatology, surgeon’s comfort level, and radiographic indications; therefore, there is no one size fits all approach. Based on our review of the literature, we aim to compare the three surgical techniques (P, AP, and LP) and highlight which clinical scenarios may be best suited for each approach and, additionally, we discuss considerations that may help facilitate preoperative discussion with the patient (Table 2).

Starting with the P approach, it has historically been the foundation of ASD correction due to its ability to address extensive deformities through a single posterior incision. One of the major strengths of this approach is its lower risk of vascular and neurologic injuries, making it a safer option for frail or elderly patients who may not tolerate prolonged surgeries. Great outcomes using the P approach are also seen when treating deformity from vertebral tuberculosis with the use of the P approach showing superior outcomes including less bleeding, shorter operative time, hospital stay, and fewer complications compared to alternative approaches (33,34). The authors compared the cost effectiveness of AP to P approaches in terms of 2-year cost per quality-adjusted life year (QALY) and found that although the QALYs gained were similar between the two approaches, the posterior approach was significantly less expensive for the index surgery and at 2-year follow up ($84,329 vs. $64,281 and $89,824 and $73,904, respectively) (11). No significant differences were seen for revision rates. It is important to note that the effectiveness margin decreased between the index surgery and the 2-year time point; thus, indicating marginal differences between the two approaches long term.

The P approach is not without its limitations. Although it is effective in many scenarios, it may fall short in achieving optimal sagittal realignment in more severe deformities, particularly in the lumbosacral region. The absence of anterior column support can predispose patients to higher rates of implant failure and pseudarthrosis, especially in long fusion constructs. Consequently, patients with more complex deformities, such as severe long-standing deformity and severe postural imbalance, may require additional support, making combined approaches a more suitable option.

The combined AP approach leverages the strengths of both anterior and posterior techniques, providing greater mechanical stability and allowing for improved sagittal correction. The Scoliosis Research Society-Schwab classification system is widely used for grading ASD (35). It consists of four types of coronal curves (thoracic only, thoracolumbar/lumbar, double curve, or no major coronal curve) and three types of sagittal modifiers, which include sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and pelvic tilt (PT) (36). This classification system has aided the treatment decision-making for ASD and provides a way to describe and categorize radiographic findings of deformities (36). A study investigating radiographic measurements and postoperative outcomes found that compared to the P only approach, the combined AP approach provided a significantly greater sagittal correction, specifically regarding T1 pelvic angle, L1–S1 lordosis, L4–S1 lordosis, and SVA (8). The authors speculate that the added correction may stem from the advantages of anterior placement of a larger interbody graft, which provided superior lordotic correction. Combined approaches, despite being associated with a significantly longer operative time and intensive care unit (ICU) stay, showed comparable complication rates to the P approach and significantly fewer readmission and reoperations at the 2-year mark (8,17). While greater sagittal correction may be achieved via the AP approach, it is unclear if this always translates to improved clinical outcomes (12). A study by Younus et al. found that when compared to the P approach, the AP approach had a statistically greater degree of T1PA and SVA correction, greater improvement of L1–S1 and L4–S1 lordosis, although no statistical difference was seen in mechanical complication or patient-reported outcome measures (PROMs) at 2-year follow up (8). Conversely, a separate study by Passias et al. found that patients who underwent a combined AP approach were more likely to meet substantial clinical benefit in Oswestry Disability Index (ODI) at 2 years (55.2% vs. 36.9%, P=0.005) while minimizing rates of proximal junctional failure (PJF) when compared to the P approach (6.6% vs. 14.6%, P=0.044) (37). Both surgical approaches showed no significant differences in complication rates at any time point or reoperation rates within 90 days and 2 years. The authors ultimately concluded that although global realignment can be successfully reached with various approaches, the AP approach mitigated PJF and restored quality of life more so than the P approach largely due to the anterior approach’s ability to effectively normalize pelvic compensation (37).

The AP approach is associated with significant limitations, such as the need for a second incision, often necessitates a second induction of anesthesia, and requires prolonged operating times which may increase perioperative risk. Additionally, this approach is linked to increased blood loss and longer ICU stays, which may limit its use in frail and elderly populations.

As mentioned previously, when compared to P approach, the addition of the anterior approach corrects spinopelvic parameters by optimizing the restoration of lumbar lordosis and, in turn, lowers complication rates and increases fusion rates (38). Despite lower complication rates, the nature of the anterior approach carries with it a few unique complications, such as greater risks of ileus, visceral, and vascular injuries (39). Ileus is the inhibition of gastrointestinal motility and is a common complication of abdominal or pelvic surgery often resulting in increased hospital stay and potential dissatisfaction with surgical care (40). A study by Fineberg et al. concluded that the incidence of postoperative ileus following the use of a combined AP approach was 8.4%, which was significantly higher than the 2.6% demonstrated by a P approach (41). Singh et al. further investigated the outcomes and complications of the anterior approach by comparing one- and two-level ALIF from L4–S1. The authors found that two level ALIFs had significantly increased rates of major vessel injury (11.1% vs. 1.5%) and postoperative ileus (7.4% vs. 0.0%) when compared to a one level ALIF (42). Therefore, the number of levels fused anteriorly may play more of a role in the intraoperative and postoperative complication profile than the anterior approach itself.

ALIFs also increase the risk of venous thromboembolism (VTE), which includes DVT and PE, due to manipulation of the major abdominal blood vessels spanning the anterior spinal column (43). The overall incidence of VTEs across spine surgery is relatively low and ranges from 0.4% to 2.4% (44-46). While there is imperfect data for comparing VTE rates across surgical approaches in deformity patients, more extensive data exists for single level fusions. A retrospective cohort study of 9,021 patients utilized multivariable analysis via an anterior or posterior approach found that after controlling for age, body mass index (BMI), sex, race, and other potential confounders, the ALIF group had significantly higher odds of developing DVTs [odds ratio (OR) =2.210, 95% confidence interval (CI): 1.211, 4.033, P=0.010] and PEs (OR =2.679, 95% CI: 1.311, 5.477, P=0.007) (47). This highlights the need for evidence-based protocols for VTE prophylaxis amongst patients undergoing deformity surgery through an anterior approach (43,47). Early mobilization and minimizing tension of the major vessels can be critical to reduce the incidence of VTE.

Additionally, the anterior approach may be contraindicated in a patient with a history of abdominal surgery, due to aggregates of scar tissue and adhesions which distort anatomical landmarks. Thus, anterior approach related intraoperative complications, such as iliac vein laceration, increase 52% for each additional abdominal surgery a patient undergoes (48). Another drawback is the higher cost associated with this approach, both in terms of surgical resources and postoperative care, which may impact its cost-effectiveness in some patient groups (11). Lastly, the assistance from an access surgeon may be a limiting factor at locations or hospitals where this resource is not readily available. Because of this, the anterior approach may not always be feasible. Other approaches that circumvent the peritoneal cavity, such as those of the lateral approach, may be of particular benefit in these situations.

The LP approach, which includes both lateral and oblique-lateral angles, provides a minimally invasive alternative to the traditional AP method. One of the primary strengths of this approach is its ability to achieve significant deformity correction while minimizing disruption to major anatomical structures, reducing the risk of vascular or neural injury (28). Both lateral and oblique-lateral approaches are most often used for L2–L5 disc spaces (22). Fusion at the L1–L2 and L5–S1 levels are often complicated by an obstructed view from the 11th rib and iliac crest, respectively. Rib fracture or resection should be expected when performing approaches cephalad to the L2–L3 level to allow for adequate exposure of the spine (49). Unlike the LLIF technique, OLIF is suitable at the L5–S1 level although this level is more technically challenging than higher levels due to the iliac crest.

The lateral approach has many mechanical advantages, similar to the anterior approach, including the ability to insert a large lordotic interbody cage (27). However, the use of an LLIF alone is often unable to achieve significant sagittal plane correction [unless the anterior longitudinal ligament (ALL) is targeted for release] (13). As opposed to the anterior approach, the lateral approach does not require the surgeon to transect the ALL to reach the intervertebral disc. Therefore, one of the main advantages of this approach is that the stabilizing ligamentous structures of both the anterior and posterior columns remain intact, which takes advantage of the principle of ligamentotaxis when an interbody device is placed (50,51). Ultimately, this facilitates indirect decompression and deformity correction by way of restored disc height and alignment correction. A biomechanical study by Cappuccino et al. further supported this finding and found that compared to ALIF and TLIF, lateral interbody fusion provided the most segmental stability in the lumbar spine in a stand-alone construct and the addition of bilateral pedicle screw fixation further improved stability (52). Bae et al. compared all three approaches for ASD with mild to moderate sagittal imbalance and found that LP approach had the lowest rates of proximal junctional kyphosis (PJK) and mechanical failure at the upper instrumented vertebrae and less back pain, less disability, and better SRS-22 scores (14).

Intradiscal vacuum phenomenon (VP) is a radiological finding and is associated with advanced degenerative disc disease of the spine (Figure 3A) (53). Because of its ability to restore disc height, achieve indirect decompression, and no disruption of the ALL or posterior longitudinal ligament, lateral interbody fusion has proven itself as an effective tool for treating patients with VP. A study comparing the effects of VP on surgical outcomes between endoscopic decompression and OLIF, found that the OLIF group had significantly better outcomes in terms of leg pain at both 1- and 2-year follow up visits (54). The authors believe that the recurrence of radiculopathy in the group that did not undergo fusion may be due to segmental instability that was caused by the vacuum disc, making fusion the better option for treating patients with VP (54). Another study demonstrated significant increases in disc height and segmental lordosis following LLIF when VP was present on preoperative imaging, and the authors found that the addition of posterior instrumentation led to lower stress on the interbody cage and reduced the incidence of cage subsidence (55).

The LP approach has its limitations. Its approach related complications may also include injury to visceral anatomy such as the kidneys, ureters, ascending or descending colon (56). Pseudohernias are a unique complication specific to the use of a lateral, transpsoas approach. Although these are safe and reproducible techniques lateral approaches are known to cause pseudohernias via direct injury to nerves of the abdominal wall (57,58). The authors prefer blunt dissection when accessing the disc laterally to minimize this risk. Additionally, femoral nerve and lumbar plexus injury are well described complications of the lateral approach to the spine, especially one that uses a transpsoas corridor. The reported rates of motor nerve injury from a minimally invasive lateral transpsoas approach range from 0.7% to 33.6% (59). As the lumbar plexus is followed caudally, its ventral migration puts the highest risk for neural injury at the L4–L5 disc space (60). In a cadaveric study of ten specimens, Park et al. found that in the lumbar spine, the nerve trunks travelled in closer proximity to the center of the disc in the caudal direction, with a mean distance of 10.6 mm at the L4–L5 level compared to the 16.4 mm seen at L2–L3 (61). Cahill et al. reported no femoral nerve injuries at any level other than the L4–L5 disc space in their study of 118 patients that underwent LLIF via a transpsoas approach (62). Uribe et al. compared symptomatic neuropraxia in 323 patients who underwent L4–L5 minimally invasive lateral interbody fusion and reported that retraction time was significantly longer in those with symptomatic neuropraxia compared to the those without (32.3 vs. 22.6 min, P=0.031), providing evidence that increased retraction time is a predictor of declining neural integrity (63). These studies highlight the importance of practicing caution when performing the lateral approach in order to minimize approach related complications such as utilizing real time neuromonitoring, limiting retraction time, and blunt dissection.

Likewise, a history of multiple retroperitoneal surgeries can be a contraindication, as the buildup of scarring and adhesions may obscure anatomical landmarks intraoperatively. Other contraindications include lateral position of the great vessels, the presence of transitional psoas or the “Mickey Mouse” sign on magnetic resonance imaging (MRI; which may be associated with more anteriorly located branches of the lumbar plexus), and a high riding iliac crest which obstructs access to the L5–S1 disc space (64,65).

The lateral approach may not be suitable for all spinal levels, particularly at the L5–S1 level, and it may require a retro-pleural approach in the thoracic and upper lumbar spine (66). Further, as discussed above, the L4–L5 level significantly increases the risk of neurologic injuries and not all patients are good surgical candidates for this approach. Moreover, achieving adequate deformity correction using the LP approach alone can be challenging in cases of severe deformity, necessitating an anterior column release of the ALL or the use of additional posterior column osteotomies. Furthermore, specialized training and equipment are required for these procedures, which may limit their adoption in smaller centers. As with the AP approach, the longer operative times and ICU stays may pose challenges for patients who cannot tolerate extended procedures (17).

Limitations and future research

To our knowledge, there are no studies that compare the P approach, combined AP and combined LP approach with one another, while clearly stating each approach’s benefits, limitations, and relevant complications. This review is targeted towards early career surgeons trying to determine the optimal surgical approach for their patients by reviewing the literature and showing case-specific examples. The review may also fill knowledge gaps for more senior spine surgeons looking for a comprehensive review of the current literature to determine targeted approaches for certain patients.

There are several limitations including the lack of standardized inclusion criteria across all the studies that were included in this review. Retrospective and prospective studies comparing the surgical approaches usually included follow up to 2 years, therefore, long term outcomes could not be inferred with accuracy. Some studies had small sample sizes, which may not accurately represent the true ASD population. Next, selection and expertise bias may be inevitable in multicenter studies as patient selection, preoperative planning, surgical preference, and surgical skill vary between institutions. Several radiographic studies were used to compare radiographic parameters. These studies only shed light on alignment targets and outcomes, and therefore, patient-reported outcomes and satisfaction could not be inferred solely from improved spinal alignment.

The studies that were used to compare outcomes between the three approaches of interest used open screw placement as opposed to percutaneous screw placement. This is an important distinction to make as an open posterior fusion allows for improved access for posterior column osteotomies and pedicle subtraction osteotomies to achieve sagittal correction, while potentially improving spinal fusion rates due to greater soft tissue clearance. There is growing interest in minimally invasive spine surgery, so increased publications using the percutaneous technique are expected and may further shape how spinal deformity is managed in the future.

Likewise, longer term studies are needed to accurately assess rates of revision and complications as deformity patients are prone to long term complications including rod fracture and adjacent segment disease. Lastly, more studies, whether retrospective or prospective, comparing the three approaches and their associated PROMs would be of great benefit to evaluate clinical improvement from the patient’s perspective and to further elucidate optimal approaches amongst certain patient populations.

Conclusions

Overall, each approach has distinct strengths and limitations that make them suitable for specific patient populations and deformity characteristics. The P approach remains a strong option for mild to moderate deformities, offering effective outcomes with lower perioperative risk and cost. In contrast, the combined AP approach should be reserved for cases requiring substantial sagittal correction and mechanical stability, despite the increased operative risk and cost. Finally, the LP approach represents a viable middle ground for patients with lumbar deformities, offering improved correction with reduced complications compared to traditional AP techniques.

Future research should focus on refining patient selection criteria to match the appropriate approach with individual patient needs. Large-scale, long-term studies comparing these techniques will be essential to provide definitive guidance, optimize surgical outcomes, and allow for better understanding of long-term outcomes for ASD patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal for the series “Adult Spinal Deformity: Principles, Approaches, and Advances”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-5/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-5/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-5/coif). The series “Adult Spinal Deformity: Principles, Approaches, and Advances” was commissioned by the editorial office without any funding or sponsorship. M.J.L. served as the unpaid Guest Editor of the series and serves as an Editor-in-Chief of AME Surgical Journal from December 2024 to December 2026. He serves as a consultant for Kuros Biosciences. He is also on the Advisory Editorial Board for Spine, serves as Deputy Editor for Primary Research for Clinical Spine Surgery. N.A.P. reports a paid consulting agreement with Stryker Spine, non-monetary research support from Alphatec Spine (ATEC Spine), and fellowship support from Medtronic, Inc. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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