496- Neurological Risks After ALIF Surgery That Every Chiropractor Should Know

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On this week's episode, we are back with more research and it is another good one. A brand new study 2025 from the Global Spine Journal. And it is all around the incidence types and risk factors of neurological complications following an alif, an anterior lumbar inebriety fusion. And this surgery is used a ton to correct spinal deformity and for degenerative conditions. I am sure that you have seen patients in your practice that have had alifs or maybe are thinking about having one in the future. We're gonna highlight what some of the neurological complications are so you can better communicate that to your patients and also so post surgically you can be aware of what you are dealing with. Now, before we get started, I wanna say a few words about one of my new partners, Leander Tables. They are offering you as a listener of this podcast, $1000 off their series 950 Flexion Distraction with Elevation table. And it is awesome. You can connect with their team directly on their website, mention the Evidence based chiropractor or if you click down in the show notes, head over and buy online. You can use the code EBC for evidence based chiropractor EBC 2025 and it'll give you $1,000 off the best tables in the business. But as I said at the top, we are talking research today. The title of the study is Neurological complications following Anterior Lumbar Inner Body Fusion. That's what we call an alif, a systematic review. And again it came out in Global Spine Journal just this year in 2025. If you've been following and listening along this podcast, you probably know I was an executive at two different orthopedic groups. I was the co director of Orthopedic Total Wellness at Florida Orthopedic Institute, deeply tied in with Tampa General Hospital, USF Health, all of that where I was taking care of patients. Then I moved over to now defunct Laser Spine Institute where I was the director of Total Spine Care, bringing all of the conservative care arm into their multiple 7 ASCs, Ambulatory Surgery Centers that were spread throughout the United States. And alifs were a big deal at both surgical practices. And here is a crazy stat that we're gonna come back to if you're like, wow, I haven't heard of that too much. Get this. The annual volume of ALIF procedures has increased 600% between the year 2000 and 2019. Are these wonderful surgeries that are helping way more people than ever before? Well, that's in the eye of the beholder, let's put it that way. But the bottom line is there is a lot of people. A 600% increase between the year 2000 and the year 2019. What does that tell us? That tells us that clearly there are more doctors being trained on how to do this. And very clearly there are more doctors making this recommendation. Now, as you are probably aware, anterior lumbar interbody fusion means you're going in through the front. It is going anterior through for lack of better say it. I'll say the lower stomach. And it is massively more invasive than a posterior surgery, which, which there are a bunch of different lifts lumbar interbody fusions, depending upon the angle that happens posteriorly. But anterior tends to be almost every single time. There are always exceptions, but almost every single time a much bigger surgery. Well, what does that mean? That means more anesthesia, that means a longer surgical time, that means more risk for the patient, that means more skill necessary for the surgeon, and it means more money collected because of all of those items. So I'll let you put the math together on that. But we're gonna talk about those neurological complications based upon this study. Couple key findings. They looked across 16 studies and found the overall complication rate, neurological specific complication rate was between 4 and 8%. And that was divided into two big categories. Nerve root or lumbar plexus injuries, or sympathetic nerve injuries. So those were kind of the two big categories. And I want to emphasize and go back 4 to 8%. That's pretty high. And that's a neurological complication rate, not an overall complication rate. Meaning your overall complication rate may include things like infection, may include things like rarely, but death due to anesthesia usage, all of those. This is strictly neurological. And you're looking at up to an 8% complication rate. I don't believe too many people are aware at still what I'll say is how risky this is because when you add on the other complications, infection, all those things we just discussed, your complication rate on this can easily surpass 20 to 30% with the neurological complication, which is ironically, most of the time what you're trying to fix at up to 8%. Now, they did discover that Alifs at L5S1 carried the highest risk of nerve injury. And that's something to keep in mind because almost up to 18% risk in spinal deformity cases. Adult spinal deformity patients had rates as high as 38%. These are high risk scenarios. And sympathetic nerve injuries ranged up to 45% depending upon the surgical approach. So these are risk factors to keep in mind. For adults, the risks went up. For L5s1, the risks went up, and sympathetic nerve injuries went up when doing alifs, and specifically at that L5S1 level, and specifically when there was deformity attempting to be corrected. So as your patients are talking to you and they're like, I don't know what to do. I've been rec. Just because somebody's been recommended something does not mean it's the best thing for them to do. Now, there are, of course, red flags where the options become limited and you have to do what you have to do. But in many cases, these are elective surgeries, which means the patients have choice. So I want to tread this carefully, but also instill in you the confidence to have these discussions. Now, you're not a surgeon, if you're listening, as a chiropractor, nor should you necessarily give direct surgical advice. But there are plenty of MDs that are happy to give advice in terms of going to see a chiropractor or not. I'm not saying you need to dissuade patients from having things done. What I am saying is that many of them, when they're recommended this, believe that that is the unified and unilateral tract. And for many patients, that might not be the case. For some, it is. And your job, being the doctor doctor, is to help them parse that out, to help them understand the best next steps for them and help them understand the ramifications for each one of those steps. And those ramifications are whether they go to you or whether they go to surgery or anything in between, the best that you can do is guide that patient along. That's what they're paying you for. So stepping up and understanding what these terms mean, what the challenges are, what the benefits are, is really part of being a great chiropractor. So, as I said at the top, there were a couple different types of neurologic complications they identified. One was what they referred to as a nerve root or a lumbar plexus injury. These symptoms are pretty obvious for us, Things like ridicular pain, motor weakness, sensory deficit. And these became really common in high lordotic corrections. So when there was A huge lordosis being corrected, especially at the lower lumbar level. There is a high incidence of foraminal stenosis as a result over that. When people are using large implants, it could be over distraction and that could cause compression on that L5 nerve. So these were important things to keep in mind. Again, chances are you have X rays, you might have an mri. And so helping patients understand this, really, really important. Then there are things that they refer to as sympathetic nerve injuries. And this had higher risk at L4, L5 and above, where the sympathetic chain lies pretty midline where challenges can happen. And these could result in a variety of different dysfunctions, none of which were pleasurable, let's put it that way. So temperature changes, groin dysesthesia, all of these things and many more could happen as a result of that. So it's really, really important that the surgeon, and this is something we can't control, but evaluates pre op CTs for osteophytes and foraminal narrowing, that they're making the best approach decision on understanding the territory and turf that they're gonna come up against when they get in and start doing that surgery. Really, really important. Now, intraoperative monitoring was a big thing when I was at these orthopedic groups. And in this review, they say one study found intraoperative monitoring helpful, another found false positives and negatives with no outcome benefit. Probably more for the surgeons to decide, of course, whether or not they want to use that. But it's not an absolute, in other words. So based upon that 600% increase, it's important for all of us to know that alifs are now mainstream, like anterior approaches and placing implements in the lumbar spine. Is not this like weird one off thing. It's being done more and more and more and it helps us understand when this is done and what could go wrong. So L5S1, that is a hot spot for radiculopathy post surgically, especially when there's deformity corrections taking place. Now, if we want to look at some sheer numbers, we see ALIF procedures were at just a little bit above 4,000 procedures performed in 2000 and about 30,000 procedures performed in 2019. 600% increase posterior lateral peelift fusions, 84% increase posterior lumbar antibody fusion, less than 1% growth. Posterior lateral 84% growth. So those are wildly different than 600% growth with that anterior approach. So Alifs have appeared to become really the preferred tool for restoring lumbar lordosis, even with the surgical risks. Now, this is not a. You just get to choose, right? Meaning if somebody has, let's say, bilateral pars defects, they're falling off the top. There's only so much correction you can do posteriorly, which is why the alif, despite the fact that there's increased complication rates, might become the preferred approach. But, but it's important to understand it doesn't mean it fixes the problem automatically. Many patients, people do believe, people in your community right now believe, well, surgery is what fixes it, but I'm not willing to do that yet. As if it's a guaranteed output. The irony being you ask most patients, hey, has any of your friends, family, anybody you know had surgery? And almost any of them can give you. Because one third get better, one third, say about the same, one third get worse. Almost all of them know multiple people who have not gotten better or gotten dramatically worse. Yet there's this amnesia, short term memory loss associated with that, where they're aware of it, but then for them it's like, oh, it's going to fix my problem. I just don't know if I want to do that yet. So helping guide people pre surgically and ensuring that they undergo everything that they can, that's, that's reasonable prior to having surgery, really, really, really important. So there are some also key takeaways I'm going to say that we can have as chiropractors, helping them make educated decisions by helping them ask the right questions. Is this, you know, asking the surgeon, helping them understand it's okay to ask the surgeon? Is this the best approach? And why are you concerned about me having a pinched nerve for amylo stenosis? A pinched nerve after surgery. How many of these have you performed and what's the success rate? And I deem success patients finding resolution of their symptoms because success is in the eye of the beholder. So you want the patient to define it to the doctor so they will give them an answer. So we can see in this research, you can probably see in your office, just because ALIF procedures are being done way more doesn't mean there's better outcomes. The big challenges that take place at L5S, one can create a second wave of symptoms. Now there's opportunity for you to help those individuals that have symptoms, especially if it's adjacent segment disease. As you fuse a segment, the adjacent segments, of course undergo excess stress and load, which accelerates the degenerative processes and deterioration of those adjacent segments, I. E. Degenerative segment disease. So we can help with that Tremendously. But again, many people believe, well, I had surgery, no way can I do anything now. I can't go to a chiropractor now. They're going to break apart that hardware. That's nearly impossible, but especially after they've been cleared by the surgeon. Getting motion into those adjacent segments, you don't want to get motion into the fusion, of course, but into that adjacent segment is some of the best thing you can do not only for the adjacent segment, but also for that fused segment. If the adjacent segments start deteriorating and not moving well, that places conversely more stress and strain on the fused segment. And when it's not fully fused, that can create a cascade of symptoms muscularly along with everything else. So it is absolutely in the best interest of many patients post surgically. I believe it should be standard, quite frankly, in many cases post surgically to see a chiropractor. They go in and they address the muscular deterioration through physical therapy often, but they never, if they rarely, I should say, address the segmental dysfunctions, which is quite often much of what got them there in the first place. So there's a role, I say all this to say there's a role for you, for me, for conservative care before and after. Before and after. So I'll ask you doctor, do you have pre surgical programs and processes in your practice? Do you have post surgical programs and processes in a way that they're clearly defined as that even if it shares a lot from your non surgical programs and how you take care of people that have nothing to do with surgery? Have you defined it enough so that people in your community know how to make a decision? They can't make that leap and that jump, but you can help them understand it and help guide that path by letting people know again, putting out social videos, putting it in an email. Putting it in what? Wherever your patients are, however you communicate, wherever you market, we take care of people pre surgically. As a matter of fact, that is one of the best things you can do is be prepared for surgery because it reduces downtime, it helps you get up and moving and it ultimately improves the results of that surgery. Oh, by the way, post surgically, did you know we help people post surgically? While you may believe that after you've had a fusion that a chiropractor is not the best choice for you, after you're cleared by your surgeon, it often is the best choice for you. Along with that physical therapy, if you are somebody who's looking to get the best results long term and really making that message super super crystal clear. And understanding all of these risks doesn't mean you have to be diametrically opposed to surgery 100% of the time. It means you get to recognize when the care that you provide can help patients avoid or better recover from it. So the more that you can understand and speak just the basics of some of this surgical language and it increases your credibility and opens up referral pathways to surgeons as well. So lot of lot of key takeaways as you can see. A lot of directions you can go with this research. Again, I will drop a link down in the show notes and before we wrap up I will say a few words about turncloud. They are the EHR that has stripped away everything that's not essential, made everyday function simpler, and created an app where no one needs a user manual. How awesome is that? If you have not connected with their team and at least had a conversation man talk. 15 minutes of your time could save you thousands of hours down the road and tons of money as well. Visit them at turncloud.com, let them know you heard about them from the Evidence Based Chiropractor. They will hook you up with a special offer. We are coming down on our 500th episode where we're going to have a fun time. A lot of giveaways. Whether this is your first episode or your 496th or whatever it is episode. Listening. Thank you so much for tuning in. If you've not left a reading or review, I would appreciate it if you did. It helps more and more docs find out about this podcast. Thank you so much for being a chiropractor. Thank you for listening. Have a fantastic week and practice and I will talk to you soon.

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