Review Article Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications Dexter K. Bateman, BS*, Paul W. Millhouse, MD, Niti Shahi, BS, Abhijeet B. Kadam, MD, Mitchell G. Maltenfort, PhD, John D. Koerner, MD, Alexander R. Vaccaro, MD, PhD Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA Received 26 May 2014; revised 22 December 2014; accepted 18 February 2015 Abstract BACKGROUND CONTEXT: The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated. PURPOSE: To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to de- crease complication rates. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to iden- tify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally in- vasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category. RESULTS: Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or re- vision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were as- sociated with higher complication rates, whereas lower complication rates were observed in patients FDA device/drug status: Not applicable. Author disclosures: DKB: Nothing to disclose. PWM: Stock Owner- ship: Globus Medical ($0). NS: Nothing to disclose. ABK: Nothing to dis- close. MGM: Nothing to disclose. JDK: Nothing to disclose. ARV: Royalties: DePuy (C), Medtronic (H), Stryker Spine (G), Biomet Spine (C), Globus Medical (F), NuVasive (B), Aesculap (B); Stock Ownership: Replication Medica (15,000 shares, value B), Globus Medical (123,398 shares, value I), K-2 Medical, Paradigm Spine (975,000 shares, value F), Stout Medical (1% company, value E), Spine Medica (25,000 stock op- tions, unknown value), Computational Biodynamics (50% ownership, un- known value), Progressive Spinal Technologies (30% ownership, unknown value), Spinology (8,125 shares, unknown value), Small Bone Innovations (15,000 shares, unknown value), Cross Current (62,500 shares, paid 50,000), Syndicom 2,750 shares, value 5,032), In Vivo (123,935 shares, unknown value), Flagship Surgical (Invested 50,000, value D), Advanced Spinal Intellectual Properties (30% ownership, unknown value), Cytonics (25,000 shares, unknown value), Bonovo Orthopedics (100,000 shares, paid 116,500), Electrocore (50,000 shares, unknown value), Gamma Spine (15% ownership, unknown value), Location Based Intelligence (20% ownership, unknown value), Flow Pharma (2,000,000 nonqualified stock options, unknown value), R.S.I (50% ownership, unknown value), Roth- man Institute and Related Properties (practice, unknown value), Innovative Surgical (30% ownership, unknown value), Design (Unknown), Spinicity (53,000 shared, 3.4% ownership); Consulting: Gerson Lehrman Group (B), Guidepoint Global (B), Medacorp (B), Stout Medical (B), Innovative Surgical Design (B), Orthobullets (A); Board of Directors: AO Spine, In- novative Surgical Design, Association of Collaborative Spine Research, Spinicity; Grants: Stryker Spine, Cerapedics, NuVasive (C). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. Disclosures: This work had no outside funding, and the authors present no conflicts of interest in relation to this study. * Corresponding author. Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Phila- delphia, PA 19107, USA. Tel.: (404) 642-5137; fax: (215) 503-0568. E-mail address: dexterbateman@gmail.com (D.K. Bateman) http://dx.doi.org/10.1016/j.spinee.2015.02.040 1529-9430/Ó 2015 Elsevier Inc. All rights reserved. The Spine Journal 15 (2015) 1118–1132