Influence of surgical approach on sexual dysfunction following single-level lumbar fusion in men: a propensity-matched analysis

Background Sexual dysfunction represents a meaningful yet understudied complication of spine surgery, with substantial implications for quality of life. Differences in surgical exposure between anterior and posterior approaches may influence these outcomes through variation in anatomic disruption, neural risk, and perioperative course. While existing studies have reported select postoperative sexual complications in broad patient populations, comparative data specifically assessing dysfunction by operative approach among men undergoing single-level lumbar fusion remain sparse. This study compared postoperative sexual dysfunction risk following anterior-only versus posterior-only single-level lumbar fusion in men. Methods The TriNetX Research Network identified adult men who underwent single-level lumbar fusion between 01/01/2010 and 12/31/2023, with preoperative diagnoses of lumbar, lumbosacral, or thoracolumbar stenosis, spondylolisthesis, scoliosis, myelopathy, or radiculopathy. Patients were categorized by surgical approach as anterior-only or posterior-only fusion. Individuals with complex spinal pathology, preexisting urogenital disease, or prior alternative exposure were excluded. Propensity score matching was used to balance age, ethnicity, and relevant comorbidities. The primary outcome was a composite of postoperative sexual complications, including erectile and ejaculatory disorders, dyspareunia, decreased libido, and testicular or scrotal dysfunction, assessed at 1, 3, 6, 9, and 12 months after surgery. Results Of 12,369 eligible patients, 10,606 underwent posterior-only fusion and 1763 underwent anterior-only fusion. After propensity score matching, 1761 patients remained in each cohort with well-balanced baseline characteristics. Compared to posterior-only, anterior-only fusions were associated with significantly higher odds of sexual dysfunction at six (OR 2.09, 95% CI[1.12–3.88]), nine (OR 1.93, 95% CI[1.15–3.25]), and twelve months (OR 1.61, 95% CI[1.03–2.52]). Conclusions In this multi-institutional cohort of adult men undergoing single-level lumbar fusion, anterior exposure was associated with increased odds of delayed postoperative sexual dysfunction compared to posterior-only approaches, underscoring surgical approach as a clinically important contributor to postprocedural sexual outcomes.