Anterior Lumbar Interbody Fusion (ALIF)

In an anterior approach (ALIF), Dr. Kazarian accesses the spine through a small incision in the lower abdomen, working from the front of the body. In a posterior approach, the incision is made in the back, and the surgeon works around the spinal muscles and nerves to reach the disc space. The anterior approach offers the advantage of leaving the back muscles completely undisturbed and allows placement of a larger implant for better support and spinal curvature restoration. ALIF is typically combined with posterior robotic percutaneous pedicle screws placed through small incisions in the back to provide additional stability while the fusion heals. Dr. Kazarian will recommend the approach that is best suited to your specific condition and spinal anatomy.

The incision for the anterior portion of ALIF is made in the lower abdomen, typically a horizontal or slightly oblique cut below the belly button. It is usually three to five inches in length, though the exact size depends on factors such as the number of spinal levels being treated and your body type. The abdominal muscles are separated along their natural fiber lines rather than cut, which helps with healing. Additionally, small incisions are made in the back for the posterior robotic percutaneous pedicle screws. All incisions are closed with dissolvable sutures or surgical staples and typically heal into thin, subtle scars over time.

The major blood vessels of the body, including the aorta and vena cava (or the iliac arteries and veins), run directly in front of the lumbar spine. To safely reach the disc space from the front, these vessels must be carefully identified and gently moved aside. A vascular surgeon or specialized access surgeon performs this part of the procedure because they have extensive training and experience in handling these critical structures. Their involvement significantly reduces the risk of vascular injury and ensures the safest possible access to the spine for Dr. Kazarian.

Anterior lumbar interbody fusion with posterior robotic percutaneous pedicle screws typically takes between two and four hours, depending on the number of spinal levels being fused and the complexity of your individual anatomy. The procedure involves two stages: the anterior portion (performed through the abdomen with a vascular surgeon) and the posterior portion (placement of robotic pedicle screws through small incisions in the back). You should plan to be at the hospital for the entire day of surgery, including pre-operative preparation and initial recovery time in the post-anesthesia care unit.

After ALIF, you may experience soreness at the abdominal incision site and some residual discomfort in the lower back from the posterior screw placement. Many patients report that their preoperative leg pain is significantly reduced or gone immediately after surgery. Abdominal soreness, mild bloating, and temporary changes in appetite are common in the first one to two weeks due to the surgical approach through the abdomen. Dr. Kazarian will send you home with the following medications as needed: • Tylenol (acetaminophen) 500–1000 mg every 6 hours for mild pain • Flexeril (cyclobenzaprine) 5 mg every 6 hours for muscle spasms or soreness • Oxycodone 5–10 mg every 4–6 hours for moderate to severe pain not controlled by Tylenol alone Ice therapy and frequent short walks also help reduce pain and swelling. Most patients are able to gradually wean off prescription pain medications within four to six weeks and transition to over-the-counter options.

Recovery from anterior lumbar interbody fusion is a gradual process that occurs in stages. Most patients spend one to three days in the hospital after surgery. The first two weeks at home are focused on managing pain, protecting the surgical site, and gradually increasing walking distance. Many patients notice improvement in their symptoms within the first few weeks. By six weeks, most patients experience significant improvement and should be weaning off of most pain medications. Bending, twisting, and lifting restrictions are in place for the first six weeks. At the six-week mark, most patients are performing activities of daily living, physical therapy begins, and activity increases gradually from there. The bone graft takes approximately six to twelve months to fully fuse into solid bone, and Dr. Kazarian will monitor fusion progress with periodic imaging at your follow-up appointments.

As with any surgical procedure, ALIF carries some risks. General surgical risks include infection, bleeding, blood clots, and reactions to anesthesia. Risks specific to the anterior approach include potential injury to the major blood vessels near the spine, which is why a vascular surgeon assists during the procedure. Temporary ileus, a condition where bowel function is temporarily slowed, can occur due to the abdominal approach but usually resolves within a few days. Other possible complications include retrograde ejaculation in male patients (a rare risk related to nerve disturbance near the spine), nerve injury, hardware complications such as screw loosening or rod breakage, nonunion (pseudarthrosis), and adjacent segment disease. Your surgical team takes extensive precautions to minimize these risks, and serious complications are uncommon.

In the vast majority of cases, the titanium screws, rods, and interbody cage remain in your spine permanently and do not need to be removed. Titanium is biocompatible, meaning your body tolerates it very well, and the hardware is designed to last a lifetime. Once the bone has fully fused (typically within six to twelve months), the screws and rods serve a secondary role since the solid bone fusion itself provides the primary stability. In rare cases, hardware may need to be removed if it causes persistent discomfort, becomes loose, or if an infection develops around it. The hardware is safe for most MRI scans, though you should always inform any medical provider that you have spinal implants. You will receive an implant card with details about your specific hardware for your records.

Dr. Kazarian requires a lumbar brace (also called a lumbar orthosis or LSO) to be worn for six weeks after fusion surgery. The brace should be worn as much as possible during this period, as it provides external support to the healing spine, limits excessive bending and twisting, and serves as a helpful reminder to maintain good posture and body mechanics. In some cases, Dr. Kazarian may also prescribe a bone stimulator to help promote fusion healing. It is important to wear the brace exactly as directed, as consistent use during the first six weeks supports the best possible outcome.

Physical therapy is a critical component of your recovery and plays a major role in achieving the best possible outcome. Therapy typically begins at six weeks after surgery, once your incision has healed and Dr. Kazarian gives clearance. Early sessions focus on gentle core activation, posture training, and safe body mechanics for daily activities such as sitting, standing, and walking. As healing progresses, your therapist will introduce progressive core strengthening, flexibility exercises, and functional training tailored to your goals. Most patients attend physical therapy two to three times per week for two to four months. A home exercise program will also be prescribed for you to perform on the days between therapy visits. Consistent participation in physical therapy helps rebuild the muscular support around your spine, improves mobility, and reduces the risk of future problems.

Most patients are cleared to resume driving approximately six to eight weeks after ALIF surgery, though this timeline can vary based on your individual recovery, the number of levels fused, and Dr. Kazarian's assessment. You should not drive while taking any narcotic or sedating pain medications, as they impair your reaction time and judgment. Before resuming driving, you should be able to sit comfortably for at least 20 to 30 minutes, move your foot quickly and confidently between the gas and brake pedals, and check your mirrors by turning your upper body without significant pain. Dr. Kazarian will let you know when it is safe to get back behind the wheel. For the first few drives, consider starting with short trips in low-traffic areas to rebuild your confidence.

Your return-to-work timeline depends primarily on the physical demands of your occupation. Patients with sedentary or desk-based jobs can often return to work within four to six weeks, initially on a part-time or modified-duty basis if possible. Jobs requiring light physical activity such as occasional walking or standing may require eight to twelve weeks of recovery. Occupations involving moderate to heavy lifting, prolonged standing, bending, or manual labor typically require three to six months before a safe return, and Dr. Kazarian may recommend a gradual return-to-duty program. Your surgical team can provide work restriction documentation for your employer and will clear you for progressive increases in activity at each follow-up visit based on your healing progress.

The bone graft in an ALIF typically takes six to twelve months to mature into solid, fully healed bone, though the exact timeline varies from patient to patient. Early signs of fusion are often visible on X-rays by three to four months, but solid bridging bone throughout the entire graft site generally requires nine to twelve months. Factors that influence fusion healing time include your age, nutritional status, bone density, whether you use tobacco products (which significantly impairs bone healing), and the number of levels fused. Dr. Kazarian will monitor fusion progress with periodic imaging at your follow-up appointments. It is important to understand that while you will feel progressively better during this time, the biological process of bone fusion continues working beneath the surface for many months. Following your activity restrictions and avoiding smoking are two of the most important things you can do to support successful fusion.

Dr. Kazarian completed his undergraduate education at Princeton University and earned his medical degree from the University of Michigan Medical School. He completed his orthopaedic surgery residency at Harvard Medical School and Massachusetts General Hospital, followed by a fellowship in spine surgery at the Mayo Clinic.