AIM: Over the past decade, spinal arthrodesis with or without instrumentation has become a common technique in the surgical treatment of symptomatic degenerative disease of the lumbar spine. Interbody fusion at L5–S1 may be achieved anteriorly (anterior lumbar interbody fusion [ALIF]), posteriorly (posterior lumbar interbody fusion [PLIF]), or via the neural foramen (transforaminal lumbar interbody fusion [TLIF]). These techniques have specific advantages and pitfalls, making none of them the ideal approach for lumbosacral fusion. The more recently described transsacral axial lumbar interbody fusion (AxiaLIF) addresses some of the concerns of the previous fusion techniques. Early evidence suggests that the technique may be performed safely to achieve L5–S1 fusion for degenerative disc disease, spondylolisthesis, and at the distal end of long posterior fusion constructs.

MATERIAL and METHODS: A literature search using PubMed was performed to identify articles published on L5-S1 fusion. Articles reviewed included L5-S1 interbody fusion methods and clinical fusion results.

CONCLUSIONS: Interbody fusion can be performed through an anterior, posterior, transforaminal, transsacral, or lateral approach. The choice of surgical method depends on the pathology, the patient’s history of previous surgery, and the surgeon’s training and preferences. Factors considered when determining the approach to the interbody space are previous surgeries, size of the implant to be placed, and the potential injury to neural and vascular structures, as well as to the musculature. This review article discusses the L5-S1 fusion problems in different surgical techniques and their advantages and disadvantages to each other.