Comparative Analysis of Complications and Results of Anterolateral Lumbar Interbody Fusion Approaches: A Spanish Multicenter Prospective Cohort Study

Degenerative lumbar disorders are commonly treated with lumbar interbody fusion, but comparative evidence among ALIF, OLIF, and XLIF remains limited. This prospective multicenter observational cohort study compared perioperative outcomes, complications, and patient-reported outcomes (PROMs) after single- or multi-level ALIF, OLIF, or XLIF in 242 consecutive adults (108, 75, and 59, respectively) treated at Spanish centers. Age and surgical indications differed significantly across groups (p < 0.05), reflecting indication-based approach selection. Primary outcomes were intra- and postoperative complications through 6 months; secondary outcomes included operative time, blood loss, visual analog scale (VAS) pain scores, and the Oswestry Disability Index (ODI). XLIF had the shortest operative time (median, 63 min) and lowest blood loss. Overall intra- and postoperative complication rates were 3.3% and 7.8%, with no significant overall differences among techniques, although patterns differed: vascular injuries were associated with ALIF, cage subsidence was more frequent after XLIF, neurological deficits occurred with similar frequency in the XLIF and OLIF groups, and OLIF had the lowest intraoperative rate. All groups showed significant VAS and ODI improvements, with greater 6-month gains after ALIF and OLIF than after XLIF. These approaches are effective but have distinct risk–benefit profiles, supporting individualized selection.