Open Versus Percutaneous Posterior Fixation Following Anterior or Lateral Lumbar Interbody Fusion : A Systematic Review and Meta-Analysis

Systematic review and meta-analysis. To compare perioperative, radiographic, and functional outcomes between open and percutaneous posterior fixation following anterior or lateral lumbar interbody fusion (ALIF/LLIF). Posterior fixation enhances construct stability after ALIF or LLIF, yet the optimal approach, open versus percutaneous, remains debated. While minimally invasive surgery (MIS) reduces tissue disruption, open fixation may offer superior sagittal correction, particularly in adult spinal deformity (ASD). Prior meta-analyses have not isolated ALIF/LLIF procedures. Following PRISMA guidelines, PubMed, Embase, and Google Scholar were searched (January 2000-January 2025). Comparative studies evaluating open versus percutaneous posterior fixation after ALIF/LLIF were included. Outcomes included sagittal parameters, perioperative variables, postoperative events and patient-reported outcomes. Meta-analyses were performed using random- or fixed-effects models depending on heterogeneity ( I2 >50%). Thirteen studies (912 patients; 454 open, 458 percutaneous) met inclusion criteria. For radiographic outcomes: No overall difference in &#x394; lumbar lordosis (LL), &#x394; pelvic incidence-LL, or &#x394; sacral slope; however, open fixation achieved greater sagittal correction in ASD (&#x394;LL=12.9&#xb0; [95% CI: 0.01-25.87, P =0.05], PI-LL=-4.1&#xb0; [95% CI: -7.88, -0.38, P =0.03], SS=+2.5&#xb0; [95% CI: 0.38-4.58, P =0.02]). For perioperative outcomes, percutaneous fixation reduced EBL (-387&#xa0;mL [95% CI: -575.72, -197.71, P <0.0001]), OR time (-65&#xa0;min [95% CI: -93.90, -15.82, P =0.006]), LOS (-1.7&#xa0;d [95% CI: -2.42, -1.01, P < 0.00001]), and transfusion risk (OR: 0.26 [95% CI: 0.11-0.58, P =0.001]). For postoperative outcomes, no significant differences in reoperation, fusion, or adjacent segment disease incidence; percutaneous fixation improved pain-medication independence (OR: 4.29 [95% CI: 1.20-15.36, P =0.03]). For patient-reported outcomes, percutaneous fixation yielded superior ODI (-7.1 [95% CI: -11.07, -3.21, P =0.0004]) improvements early; at 2 years, it maintained minimally better VAS back (-0.31 [95% CI: -0.54, -0.08, P =0.009]) and ODI (-2.9 [95% CI: -5.04, -0.68, P =0.01]) scores. Percutaneous posterior fixation after ALIF/LLIF offers clear perioperative advantages, reduced blood loss, operative time, LOS, and transfusion need, without compromising fusion or long-term outcomes. Open fixation remains preferable for ASD cases requiring extensive sagittal realignment. Surgical approach should therefore be individualized based on deformity rigidity and alignment goals.