Single-position lateral anterior lumbar interbody fusion: anatomic considerations, workflow optimization, and...

In recent years, the single-position combined anterior-posterior approach has emerged as an increasingly utilized technique in lumbar fusion surgery. The approach combining posterior pedicle screw fixation with anterior lumbar interbody fusion (ALIF) performed in the lateral decubitus position is referred to as the lateral ALIF. Compared to traditional approaches that involve flipping the patient mid-surgery or staging the surgery at multiple time points, single-position lateral ALIF has been associated with shorter operative times, reduced estimated blood loss (EBL), shorter hospital length of stay, and lower rates of postoperative ileus, while maintaining comparable rates of fusion, complications, and reoperation. The lateral position also facilitates access to the retroperitoneal space through gravitational displacement of the abdominal contents and can permit simultaneous anterior and posterior surgical exposure. However, safe and effective execution of this approach requires familiarity with the unique anatomic, vascular, and workflow considerations associated with lateral positioning. The purpose of this review is to describe the technical details of single-position lateral ALIF surgery, focusing on surgical anatomy, indications and patient selection, surgical technique, workflow optimization, integration of navigation technologies, and perioperative, radiographic, and clinical outcomes. Preoperative assessment of spinopelvic alignment, vascular anatomy, psoas morphology, and prior abdominal surgery is essential. Intraoperatively, coordinated positioning, simultaneous anterior and posterior exposure, and integration of fluoroscopy, navigation, or robotic assistance can facilitate efficient and accurate placement of instrumentation. Current evidence suggests that single-position lateral ALIF provides comparable radiographic and clinical outcomes to traditional dual-position approaches; however, existing studies are predominantly retrospective and heterogeneous, and long-term clinical outcomes remain incompletely characterized. This review provides a practical framework for surgeons seeking to incorporate single-position lateral ALIF into their practice.