BACKGROUND CONTEXT: Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches. PURPOSE: To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery. DESIGN: Prospective, multicenter, international, observational cohort study. PATIENT SAMPLE: Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion. OUTCOME MEASURES: Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. METHODS: Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison. RESULTS: Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390). CONCLUSIONS: Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Centro Hospitalar Universitário São João Faculty of Medicine University of Porto Portugal; Department of Neurosurgery Hull and East Yorkshire Hospitals NHS Trust Anlaby Rd Hull HU3 2JZ United Kingdom

Department of Neurological Surgery Chung Ang University Hospital 102 Heukseok ro Dongjak gu Seoul South Korea

Department of neurosurgery AZ Delta Roeselare Menen Torhout Deltalaan 1 8800 Roeselare Belgium

Department of Neurosurgery Fakultní nemocnice Hradec Králové Sokolská 581 500 05 Hradec Králové Nový Hradec Králové Czech Republic

Department of Neurosurgery Hull and East Yorkshire Hospitals NHS Trust Anlaby Rd Hull HU3 2JZ United Kingdom

Department of Neurosurgery Kepler Universitätsklinikum Linz Hospital Road 9 4021 Linz Upper Austria Austria

Department of Neurosurgery Scientific Research Institute of Traumatology and Orthopedics Academician Baykova house 8 195427 St Petersburg Russia

Department of Neurosurgery Spine Unit Hospital Marqués de Valdecilla Av de Valdecilla s n 39008 Santander Cantabria Spain

Department of Orthopaedic Surgery East Suffolk and North Essex NHS Foundation Trust Heath Road Ipswich IP4 5PD Suffolk United Kingdom

Department of Orthopedic Surgery National Health Insurance Service Ilsan Hospital 100 Ilsan ro Ilsangdong gu Goyang si Gyeonggi 410 719 South Korea

Department of Orthopedics Hospital Universitario Cajuru Av São José 300 Cristo Rei Curitiba PR 80050 350 Brazil

Department of Orthopedics Korea University Ansan Hospital Gojan Dong Danwon Gu Ansan 425 707 South Korea

Department of Orthopedics Shanghai Tenth People's Hospital Tongji University School of Medicine 301 Yanchang Road Shanghai 200072 PR China

Department of Orthopedics West China Hospital Sichuan University No 37 Guoxue Alley Chengdu Sichuan Province PR China

Department of Spine Surgery Klinikum Magdeburg Birkenallee 34 39130 Magdeburg Saxony Aanhalt Germany

Department of Spine Surgery Service de Chirurgie du Rachis Hôpitaux Universitaires de Strasbourg Université de Strasbourg 1 Avenue Molière 67200 Strasbourg France

Orthopedics Department Hospital de Braga R das Comunidades Lusíadas 133 Braga 4710 311 Portugal

Service de Neurochirurgie La Timone AP HM Rue Saint Pierre 13005 Marseille Bouches du Rhône France

Servicio Cirugia Ortopédica y Traumatología Hospital de Manises Avenida Generalitat Valenciana 50 46940 Manises Valencia Spain

Trauma and Orthopedics Institute Volga Research Medical University Verhne Voljskaya naberejnaya18 603155 Nizhnii Novgorod Russia

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