A prospective comparison of surgical approach for anterior L4-L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion

Da Vinci Meets Globus Excelsius GPS: A Totally Robotic Minimally Invasive Anterior and Posterior Lumbar Fusion

BACKGROUND

Minimally invasive approaches to the spine via anterior and posterior approaches have been increasing in popularity, culminating in the development of robot-assisted spinal fusions. The da Vinci surgical robot has been used for anterior lumbar interbody fusion (ALIF), with promising results. Similarly, multiple spinal robots have been developed to assist placement of posterior pedicle screws. However, no previous cases have reported on using robots for both anterior and posterior fixation in a single surgery. We present a technical note on the first reported case of a totally robotic minimally invasive anterior and posterior lumbar fusion and instrumentation.

METHODS

A 65-year-old man with chronic low back pain and left greater than right lower extremity radiculopathy was found to have grade 1 spondylolisthesis at L5/S1 that worsened on standing upright. He underwent ALIF using a da Vinci robotic approach, followed by percutaneous posterior instrumented fusion with the Globus Excelsius GPS robot.

RESULTS

The patient did well postoperatively, with improvement of back and leg pain at 3 months follow-up. Radiography confirmed appropriate placement of the interbody cage and pedicle screws.

CONCLUSIONS

All-robotic placement of both ALIF and posterior lumbar pedicle fixation may be safe, feasible, and efficacious.

Minimally Invasive Transforaminal Interbody Fusion Versus Microdiscectomy Without Fusion for Recurrent Lumbar Disk Herniation: A Prospective Comparative Study

OBJECTIVE

The objective of this study was to compare the clinical outcome of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) versus standard revision diskectomy for recurrent lumbar disk herniation (RLDH).

BACKGROUND

RLDH is the most common cause of redo surgery after a microdiscectomy. Commonly, in patients without evidence of spinal instability, many surgeons would simply redo microdiscectomy, while others proceed to a redo microdiscectomy with arthrodesis. According to the literature, there is no evidence of what the best management of an RLDH would be.

METHODS

This study involved 90 patients who underwent lumbar microdiscectomy in the past and were now experiencing a new lumbar disk herniation for the first time. The patients were divided into two groups, each with 45 patients: group A received standard revision microdiscectomy, whereas group B received revision microdiscectomy with MIS TLIF.The Japanese Orthopaedic Association score, operating time, blood loss, duration of hospital stay, costs, and complications were all prospectively recorded in a database and examined. Back and leg discomfort were measured using the visual analog scale.

RESULTS

The mean total postoperative Japanese Orthopaedic Association score across the groups exhibited no statistically significant difference, nor did the preoperative clinical and epidemiological data. Although postoperative leg pain was comparable in both groups, postoperative lower back pain in group A was much worse than that in group B. Additional revision surgery was necessary for six individuals in group A. Group A had higher rates of dural rupture and postoperative neurological impairment. Group A experienced much less intraoperative blood loss, longer operation times, and postoperative hospital stays.

CONCLUSION

In patients with RLDH, revision microdiscectomy is effective. In comparison with conventional microdiscectomy, MIS TLIF reduces intraoperative risk of dural rupture or neural injury, postoperative incidence of mechanical instability or recurrence, and postoperative lower back pain.

STUDY DESIGN

Prospective, randomized, multicenter, comparative study.

Utility of the transversus abdominis plane and rectus sheath blocks in patients undergoing anterior lumbar interbody fusions

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery.

PURPOSE

Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control.

STUDY DESIGN/SETTING

Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital.

PATIENT SAMPLE

Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021.

OUTCOME MEASURES

Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room.

METHODS

Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups.

RESULTS

The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups.

CONCLUSIONS

The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Clinical presentation and surgical anatomy of sympathetic nerve injury during lumbar spine surgery: a narrative review

BACKGROUND AND OBJECTIVE

To highlight the surgical anatomy, procedural variations, presentation, and management of sympathetic nerve injury after surgery of the lumbar spine.

METHODS

PubMed and Google Scholar were searched for publications that were completed between 1951 and 2021. Relevant full-text articles published in the English language were selected and critically reviewed.

KEY CONTENT AND FINDINGS

Sympathetic injury is a highly variable postsurgical complication with a greater incidence after an anterior or oblique approach to the lumbar spine compared to posterior and lateral approaches. The direct and extreme lateral approaches reduce the need to disturb sympathetic nerves thus reducing the risk of complications. It can present in multiple manners, including complex regional pain syndrome (CRPS) and retrograde ejaculation. These complications can be transient and resolve spontaneously or be treated with medications, physical therapy, and spinal blocks. The severity of the conditions and extent of recovery can vary drastically, with some patients never fully recovering.

CONCLUSIONS

To access the lumbar spine, there are operational approaches and techniques that should be used to decrease the risk of intraoperative injury. It is crucial to understand the advantages and risks to different approaches and take the necessary steps to minimize complications. Early identification of dysfunction and adequate management of symptoms are imperative to effectively manage patients with lumbar sympathetic trunk and sympathetic nerve fiber injuries.

Is there a variance in complication types associated with ALIF approaches? A systematic review

Purpose

Anterior lumbar interbody fusion (ALIF) is a well-established alternative to posterior-based interbody fusion techniques, with approach variations, such as retroperitoneal, transperitoneal, open, and laparoscopic well described. Variable rates of complications for each approach have been enumerated in the literature. The purpose of this study was to elucidate the comparative rates of complications across approach type.

Methods

A systematic review of search databases PubMed, Google Scholar, and OVID Medline was made to identify studies related to complication-associated ALIF. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare intraoperative and postoperative complications with ALIF for each approach.

Results

A total of 4575 studies were identified, with 5728 patients across 31 studies included for review following application of inclusion and exclusion criteria. Meta-analysis demonstrated the transperitoneal approach resulted in higher rates of retrograde ejaculation (RE) (p < 0.001; CI = 0.05–0.21) and overall rates of complications (p = 0.05; CI = 0.00–0.23). Rates of RE were higher at the L5/S1 intervertebral level. Rates of vessel injury were not significantly higher in either approach method (p = 0.89; CI =  − 0.04–0.07). Rates of visceral injury did not appear to be related to approach method. Laparoscopic approaches resulted in shorter inpatient stays (p = 0.01).

Conclusion

Despite the transperitoneal approach being comparatively underpowered, its use appears to result in a significantly higher rate of intraoperative and postoperative complications, although confounders including use of bone morphogenetic protein (BMP) and spinal level should be considered. Laparoscopic approaches resulted in shorter hospital stays; however, its steep learning curve and longer operative time have deterred surgeons from its widespread adaptation.

Efficacy and radiographic analysis of oblique lumbar interbody fusion in treating adult spinal deformity

Adult spinal deformity (ASD) is usually rigid and requires a combined anterior–posterior approach for deformity correction. Anterior lumbar interbody fusion (ALIF) allows direct access to the disc space and placement of a large interbody graft. A larger interbody graft facilitates correction of ASD. However, an anterior approach carries significant risks. Lateral lumbar interbody fusion (LLIF) through a minimally invasive approach has recently been used for ASD. The present study was performed to evaluate the effectiveness of oblique lumbar interbody fusion (OLIF) in the treatment of ASD. We performed a retrospective study utilizing the data of 74 patients with ASD. The inclusion criteria were lumbar coronal Cobb angle > 20°, pelvic incidence (PI)–lumbar lordosis (LL) mismatch > 10°, and minimum follow–up of 2 years. Patients were divided into two groups: ALIF combined with posterior spinal fixation (ALIF+PSF) (n = 38) and OLIF combined with posterior spinal fixation (OLIF+PSF) (n = 36). The perioperative spinal deformity radiographic parameters, complications, and health-related quality of life (HRQoL) outcomes were assessed and compared between the two groups. The preoperative sagittal vertical axis (SVA), LL, PI–LL mismatch, and lumbar Cobb angles were similar between the two groups. Patients in the OLIF+PSF group had a slightly higher mean number of interbody fusion levels than those in the ALIF+PSF group. At the final follow–up, all radiographic parameters and HRQoL scores were similar between the two groups. However, the rates of perioperative complications were higher in the ALIF+PSF than OLIF+PSF group. The ALIF+PSF and OLIF+PSF groups showed similar radiographic and HRQoL outcomes. These observations suggest that OLIF is a safe and reliable surgical treatment option for ASD.

Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion

BACKGROUND

With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF).

METHODS

Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS.

RESULTS

A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index >30 kg/m²) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P = 0.001), preoperative benzodiazepine use (P = 0.014), 12-item Short Form mental component score (P = 0.008), estimated blood loss (P = 0.015), time to mobilization (P < 0.001), and total operative time (P = 0.020) were independent predictors for extended LOS.

CONCLUSIONS

As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.

Management of Vascular Complications during Anterior Lumbar Spinal Surgery Using Mini-Open Retroperitoneal Approach

BACKGROUND

Anterior retroperitoneal spine exposure has become increasingly performed for the surgical treatment of various spinal disorders. Despite its advantages, the procedure is not riskless and can expose to potentially life-threatening vascular lesions. The aim of this review is to report the vascular lesions that can happen during anterior lumbar spinal surgery using mini-open retroperitoneal approach and to describe their management.

METHODS

A systematic literature search was performed according to PRISMA to identify studies published in English between January 1980 and December 2019 reporting vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal approach. Three authors independently conducted the literature search on PubMed/Medline database using a combination of the following terms: "spinal surgery", "anterior lumbar surgery (ALS)", "anterior lumbar interbody fusion (ALIF)", "lumbar total disc replacement", "artificial disc replacement", "vascular complications", "vascular injuries". Vascular complications were defined as any peri-operative or post-operative lesions related to an arterial or venous vessel. The management of the vascular injury was extracted.

RESULTS

Fifteen studies fulfilled the inclusion criteria. Venous injuries were observed in 13 studies. Lacerations and deep venous thrombosis ranged from 0.8% to 4.3% of cases. Arterial lesions were observed in 4 studies and ranged from 0.4% to 4.3% of cases. It included arterial thrombosis, lacerations or vasospasms. The estimated blood loss was reported in 10 studies and ranged from 50 mL up to 3000 mL. Vascular complications were identified as a cause of abortion of the procedure in 2 studies, representing respectively 0.3% of patients who underwent ALS and 0.5% of patients who underwent ALIF.

CONCLUSION

Imaging pre-operative planning is of utmost importance to evaluate risk factors and the presence of anatomic variations in order to prevent and limit vascular complications. Cautions should be taken during the intervention when manipulating major vessels and routine monitoring of the limb oxygen saturation should be systematically performed for an early detection of arterial thrombosis. The training of the surgeon access remains a key-point to prevent and manage vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal.

Technique for Exposing Lumbar Discs in Anterior Approach Using Steinmann Wires: Arthroplasties or Arthrodesis

BACKGROUND

Due to increasing longevity, the incidence of degenerative lumbar disc diseases has increased, and surgical treatment is often necessary. In this context, the anterior approach becomes an important technique. However, one of the main limitations of this method is the need for dedicated retractors, which requires larger incisions for its positioning and increases the cost of the procedure. The objective of the present study was to describe a technique for retracting abdominal structures by anterior approaches to the lumbar spine using Steinmann wires.

METHODS

This manuscript consists of a technique description of anterior approach for lumbar spine.

RESULTS

Surgical treatment of degenerative lumbar spine disease is often necessary when the patients have symptoms refractory to conservative treatments. Many of them will be candidates for surgical treatment with anterior approach, either for arthrodesis/anterior lumbar interbody fusion or arthroplasty. Small incisions are performed for positioning the modified Langenbeck retractors and the Steinmann wires. These retractors are easily positioned and provide good exposure of the lumbar discs making it possible to implant appropriate cages for restoring the necessary height, lordosis, and sagittal balance.

CONCLUSIONS

The technique described is safe, inexpensive, and reproducible. Simple and easily accessible instruments are required in most hospital complexes.

Multimodal exercises integrated with cognitive-behavioural therapy improve disability of patients with failed back surgery syndrome: a randomized controlled trial with one-year follow-up

PURPOSE

To evaluate the effect of multimodal exercises integrated with cognitive-behavioural therapy on disability, pain, and quality of life in patients suffering from failed back surgery syndrome (FBSS), and to appraise its extent in the long term.

METHODS

By means of a parallel-group superiority-controlled trial, 150 outpatients were randomly assigned to a 10-week individual-based multimodal programme of task-oriented exercises integrated with cognitive-behavioural therapy (experimental group, 75 patients) or individual-based general physiotherapy (control group, 75 patients). Before treatment, 10 weeks later (post-treatment), and 12 months after the end of treatment, the Oswestry Disability Index (primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain intensity numerical rating scale and the Short-Form Health Survey were evaluated. Linear mixed model analysis for repeated measures was carried out for each outcome measure.

RESULTS

Significant group (p < 0.001), time (p < 0.001), and time-by-group interaction (p < 0.001) effects were found for all outcome measures. Concerning disability, between-group differences (95% confidential interval) in favour of the experimental group of -9 (-10.7; -7.3) after training and of -13.2 (-14.7; -11.7) at follow-up were found. Also, kinesiophobia, catastrophising and pain showed significant between-group differences of 9, 12.5 and 1.7 points, respectively.

CONCLUSION

The multimodal intervention proposed was superior to general physiotherapy in reducing disability, kinesiophobia, catastrophising, and enhancing the quality of life of patients with FBSS. The effects were reinforced one year after the programme ended.IMPLICATIONS FOR REHABILITATIONMultimodal exercises integrated with cognitive-behavioural therapy induced significant improvements in disability, pain, kinesiophobia, catastrophising, and quality of life of subjects with Failed Back Surgery Syndrome.A well-integrated rehabilitative team which contributes towards reaching intervention goals is advised.Physiotherapists should adopt task-oriented exercises to promote an earlier return to common activities of disabled patients.Psychologists should explain how to modify useless beliefs and support adequate behaviours, in order to produce constructive attitudes towards perceived disability.

A comprehensive review of the treatment and management of Charcot spine

Charcot spine arthropathy (CSA), a result of reduced afferent innervation, is an occurrence of Charcot joint, a progressive, degenerative disorder in vertebral joints, related mostly to spinal cord injury. The repeated microtrauma is a result of a lack of muscle protection and destroys cartilage, ligaments, and disc spaces, leading to vertebrae destruction, joint instability, subluxation, and dislocation. Joint destruction compresses nerve roots, resulting in pain, paresthesia, sensory loss, dysautonomia, and spasticity. CSA presents with back pain, spinal deformity and instability, and audible spine noises during movement. Autonomic dysfunction includes bowel and bladder dysfunction. It is slowly progressive and usually diagnosed at a late stage, usually, on average, 20 years after the first initial insult. Diagnosis is rarely clinical related to the nature of nonspecific symptoms and requires imaging with computed tomography (CT) and magnetic resonance imaging (MRI). Conservative management focuses on the prevention of fractures and the progression of deformities. This includes bed rest, orthoses, and braces. These could be useful in elderly or frail patients who are not candidates for surgical treatment, or in minimally symptomatic patients, such as patients with spontaneous fusion leading to a stable spine. Symptomatic treatment is offered for autonomic dysfunction, such as anticholinergics for bladder control. Most patients require surgical treatment. Spinal fusion is achieved with open, minimally-open (MOA) or minimally-invasive (MIS) approaches. The gold standard is open circumferential fusion; data is lacking to determine the superiority of open or MIS approaches. Patients usually improve after surgery; however, the rarity of the condition makes it difficult to estimate outcomes. This is a review of the latest and seminal literature about the treatment and chronic management of Charcot spine. The review includes the background of the syndrome, clinical presentation, and diagnosis, and compares the different treatment options that are currently available.

Back pain outcomes after minimally invasive anterior lumbar interbody fusion: a systematic review

OBJECTIVE

Minimally invasive anterior lumbar interbody fusion surgery (MIS ALIF) is a technique that restores disc height and lumbar lordosis through a smaller exposure and less soft-tissue trauma compared to open approaches. The mini-open and laparoscopic assistance techniques are two main forms of MIS ALIF. The authors conducted a systematic review that sought to critically summarize the literature on back pain following MIS ALIF.

METHODS

In March 2020, the authors searched the PubMed, Web of Science, and Cochrane Library databases for studies describing back pain visual analog scale (VAS) outcomes after MIS ALIF. The following exclusion criteria were applied to studies evaluated in full text: 1) the study included fewer than 20 patients, 2) the mean follow-up duration was shorter than 12 months, 3) the study did not report back pain VAS score as an outcome measure, and 4) MIS ALIF was not studied specifically. The methodology for the included studies were evaluated for potential biases and assigned a level of evidence.

RESULTS

There were a total of 552 patients included from 13 studies. The most common biases were selection and interviewer bias. The majority of studies were retrospective. The mean sample size was 42.3 patients. The mean follow-up duration was approximately 41.8 months. The mean postoperative VAS reduction was 5.1 points. The mean VAS reduction for standalone grafts was 5.9 points, and 5.0 points for those augmented with posterior fixation. The most common complications included bladder or urinary dysfunction, infection, and hardware-related complications.

CONCLUSIONS

This was a systematic review of back pain outcomes following MIS ALIF. Back pain VAS score was reduced postoperatively across all studies. The complication rates were low overall. MIS ALIF is safe and effective at reducing back pain in appropriate patient populations.

Impact of lumbar interbody fusion surgery on postoperative outcomes in patients with recurrent lumbar disc herniation: Analysis of the US national inpatient sample

Little information is available on associations between different lumbar interbody fusion (LIF) surgeries and postoperative outcomes. The present study aims to comprehensively investigate whether different LIF techniques are associated with postoperative outcomes such as complications and length of hospital stay. The United States Nationwide Inpatient Sample (NIS) was searched for patients diagnosed with recurrent lumbar disc herniation who underwent lumbar interbody fusion (LIF) surgeries between 2005 and 2014. Patients were categorized based on LIF approaches: anterior lumbar interbody fusion (ALIF); lateral lumbar interbody fusion (LLIF); or posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF). A total of 2625 patients were included in this study. After adjusting for age, severity of illness, and comorbidities, patients who received LLIF and PLIF/TLIF approaches had significantly shorter hospital stays than those receiving ALIF (LLIF vs. ALIF, β = -0.64; PLIF/TLIF vs. ALIF, β = -0.40). In addition, patients who received LLIF and PLIF/TLIF approaches had significantly lower risk of digestive system complications compared to those receiving ALIF (LLIF vs. ALIF, aOR = 0.25; PLIF/TLIF vs. ALIF, aOR = 0.18). In conclusion, in patients with recurrent lumbar disc herniation, LLIF and PLIF/TLIF approaches are associated with shorter hospital stays and lower risk of digestive system complications than ALIF. However, LIF approaches do not correlate significantly with the risk of postoperative bleeding or nervous system complications.

Perioperative Factors Influencing Postoperative Satisfaction After Lateral Access Surgery for Degenerative Lumbar Spondylolisthesis

BACKGROUND

Lateral access surgery (LAS) for lumbar degenerative spondylolisthesis is a minimally invasive lumbar fusion technique which has been gaining increasing popularity in the recent years. This study aims to identify perioperative factors that influence postoperative satisfaction after LAS for lumbar degenerative spondylolisthesis.

METHODS

From August 2010 to November 2014, 52 patients with lumbar degenerative conditions (16 male: 36 female, mean age 64.0 ± 8.7 years) were prospectively recruited and underwent LAS by a single surgeon. All patients were assessed preoperatively and 2 years postoperatively with Numerical Pain Rating Scale (NPRS), Oswestry Disability Index, Short-Form 36 (SF-36) scores, North American Spine Society score for neurogenic symptoms, patient satisfaction, and expectation fulfillment. Cobb angles, global lumbar lordosis, disc heights, adjacent disc heights, fusion, and subsidence were rates assessed. Multiple linear regression performed with satisfaction as dependent variable to identify predictive independent variables.

RESULTS

Lower preoperative SF-36 general health scores (P = .03), higher NPRS leg pain scores (P = .04), and longer surgical duration (P = .02) were significant predictors of lower satisfaction (P < .05). NPRS back and leg pain decreased by 80.3 and 83.0%, respectively. Oswestry Disability Index and North American Spine Society score for neurogenic symptoms improved by 76.2 and 75.9%, respectively. Ninety percent of patients reported excellent/good satisfaction. Significant correction and maintenance of Cobb and global lumbar lordosis angles were achieved. There was significant increase in disc heights postoperatively (P = .05) and no significant difference in adjacent disc heights at 2 years (P > .05). Ninety-eight percent of patients achieved Bridwell Fusion Grade 1, and 5.8% had Marchi Grade 3 subsidence.

CONCLUSIONS

Lower preoperative SF-36 general health, higher NPRS leg pain, and longer surgical duration are predictors of lower satisfaction in patients undergoing LAS for lumbar degenerative spondylolisthesis.

LEVEL OF EVIDENCE

III.

CLINICAL RELEVANCE

Identifying preoperative predictors for postoperative clinical outcome can assist clinicians in patient education prior to operation.

Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome

Objective

Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy.

Methods

Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months.

Results

The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected.

Conclusion

The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior load-bearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.

Complications and Prevention Strategies of Oblique Lateral Interbody Fusion Technique

OBJECTIVE

To analyze the early complications and causes of oblique lateral interbody fusion, and put forward preventive measures.

METHODS

There were 235 patients (79 males and 156 females) analyzed in our study from October 2014 to May 2017. The average age was 61.9 ± 0.21 years (from 32 to 83 years). Ninety-one cases were treated with oblique lateral interbody fusion (OLIF) alone (OLIF alone group) and 144 with OLIF combined with posterior pedicle screw fixation through the intermuscular space approach (OLIF combined group). In addition, 137/144 cases in the combined group were primarily treated by posterior pedicle screw fixation, while the treatments were postponed in 7 cases. There were 190 cases of single fusion segments, 11 of 2 segments, 21 of 3 segments, and 13 of 4 segments. Intraoperative and postoperative complications were observed.

RESULTS

Average follow-up time was 15.6 ± 7.5 months (ranged from 6 to 36 months). Five cases were lost to follow-up (2 cases from the OLIF alone group and 3 cases from the OLIF combined group). There were 7 cases of vascular injury, 22 cases of endplate damage, 2 cases of vertebral body fracture, 11 cases of nerve injury, 18 cases of cage sedimentation or cage transverse shifting, 3 cases of iliac crest pain, 1 case of right psoas major hematoma, 2 cases of incomplete ileus, 1 case of acute heart failure, 1 case of cerebral infarction, 3 case of left lower abdominal pain, 9 cases of transient psoas weakness, 3 cases of transient quadriceps weakness, and 8 cases of reoperation. The complication incidence was 32.34%. Thirty-three cases occurred in the OLIF alone group, with a rate of 36.26%, and 43 cases in the group of OLIF combined posterior pedicle screw fixation, with a rate of 29.86%. Fifty-seven cases occurred in single-segment fusion, with a rate of 30.0% (57/190), 4 cases occurred in two-segment fusion, with a rate of 36.36% (4/11), 9 cases occurred in three-segment fusion, with a rate of 42.86% (9/21), and 6 cases occurred in four-segment fusion, with a rate of 46.15% (6/13).

CONCLUSION

In summary, OLIF is a relatively safe and very effective technique for minimally invasive lumbar fusion. Nonetheless, it should be noted that OLIF carries the risk of complications, especially in the early stage of development.

A new "keyhole" approach for multilevel anterior lumbar interbody fusion: the perinavel approach-technical note and literature review

PURPOSE

The purpose of this study is to evaluate the feasibility and the safety of a new skin incision for minimally invasive anterior lumbar interbody fusion (ALIF): the perinavel incision.

METHODS

Demographic and clinical data from patients who underwent ALIF with the perinavel incision were collected. Indications to surgery, preoperative symptoms, radiological data, number of treated levels, intraoperative and early postoperative complications and wound-related problems were analysed.

RESULT

Ninety-seven patients underwent ALIF with this new skin incision. One hundred fifty-seven levels were treated (mean 1.7 level per patient) being L4-L5 the most frequently treated. Intraoperative complications were represented only by the venous injury with a rate of 3.09% (3 cases). Postoperative complications were all linked to skin incision issues: a case of wound dehiscence and a case of superficial infection. No case of skin necrosis occurs at 3-month follow-up.

CONCLUSIONS

In this paper, the perinavel skin incision was demonstrated to be as safe as traditional approaches for ALIF. Furthermore, with this incision it is possible to perform multilevel (L3-S1) ALIF, which means a good option in minimally invasive surgery as well as revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Sexual activity after spine surgery: a systematic review

INTRODUCTION

Sexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery. Our aim was to perform a systematic review to collate evidence regarding the impact of spine surgery on sexual function.

METHODS

A systematic review of studies reporting measures of sexual function, and incidence of adverse sexual outcomes (retrograde ejaculation) after major spine surgery was done, regardless of spinal location. Pubmed (MEDLINE) and Google Scholar databases were queried using the following search words "Sex", "Sex life", "Sexual function", "Sexual activity", "retrograde ejaculation", "Spine", "Spine surgery", "Lumbar surgery", "Lumbar fusion", "cervical spine", "cervical fusion", "Spinal deformity", "scoliosis" and "Decompression". All articles published between 1997 and 2017 were retrieved from the database. A total of 81 studies were included in the final review.

RESULTS

Majority of the studies were retrospective case series and were low quality (Level IV) in evidence. Anterior lumbar approaches were associated with a higher incidence of retrograde ejaculation, especially with the utilization of transperitoneal laparoscopic approach. There is inconclusive evidence on the preferred sexual position following fusion, and also on the impact of BMP-2 usage on retrograde ejaculation/sexual dysfunction.

CONCLUSION

Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery. Future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers. These slides can be retrieved under Electronic Supplementary Material.

Adult Degenerative Lumbar Scoliosis

Adult degenerative lumbar scoliosis is a 3-dimensional deformity defined as a coronal deviation of greater than 10°. It causes significant pain and disability in the elderly. With the aging of the population, the incidence of adult degenerative lumbar scoliosis will continue to increase. During the past decade, advancements in surgical techniques and instrumentation have changed the management of adult spinal deformity and led to improved long-term outcomes. In this article, the authors provide a comprehensive review of the pathophysiology, diagnosis, and management of adult degenerative lumbar scoliosis. [Orthopedics. 2017; 40(6):e930-e939.].

Lateral lumbar interbody fusion: a systematic review of complication rates

BACKGROUND CONTEXT

Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach.

PURPOSE

To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF.

STUDY DESIGN

Systematic review.

PATIENT SAMPLE

6,819 patients who underwent LLIF reported in clinical studies through June 2016.

OUTCOME MEASURES

Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work.

RESULTS

A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%).

CONCLUSIONS

The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.

A Less-Invasive Retroperitoneal Lumbar Approach: Animal Feasibility Study and Primary Clinical Study

STUDY DESIGN

Surgical approach development in an animal model, and a prospective study comparing clinical outcomes between novel and conventional approaches in thoracolumbar burst fracture fixation.

OBJECTIVE

To investigate the feasibility of a less-invasive retroperitoneal approach to the lumbar spine in a sheep model and to compare the clinical outcomes of anterior reconstruction in the treatment of thoracolumbar burst fractures using novel and conventional approaches.

SUMMARY OF BACKGROUND DATA

The anterior retroperitoneal lumbar approach is well established for anterior lumbar surgical procedures in both humans and animal models. However, potential concerns include the increased risk of complications such as soft-tissue trauma, and extended periods of rehabilitation postoperatively.

MATERIALS AND METHODS

A less-invasive retroperitoneal approach was designed in a sheep model with minimal soft-tissue dissection to keep the abdominal and paravertebral muscles intact. Eight sheep underwent anterior lumbar interbody fusion using this approach. In the clinical study, 48 patients with thoracolumbar burst fractures underwent anterior decompression and reconstruction. The less-invasive approach and conventional approach were applied in 12 and 36 cases, respectively. The clinical outcomes during the minimum 12-month follow-up of the 2 groups were compared.

RESULTS

With the less-invasive approach, anterior lumbar interbody fusion was accomplished in all sheep, and no surgical complications were observed. In the clinical study, operation time, blood loss, and duration of hospitalization were comparable between 2 groups. Using the less-invasive approach decreased the length of incision, 3-day postoperative visual analogue scale score, postoperative independent standing, and narcotic-dependent duration. No surgical complications were observed in either group.

CONCLUSIONS

Our results and early experience suggests that the less-invasive retroperitoneal approach is safe and effective for anterior lumbar surgery. Compared with the conventional approach, significantly better postoperative rehabilitation and abdominal muscle preservation were seen with this novel approach.

Anterior Lumbar Interbody Fusion With and Without an "Access Surgeon": A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to investigate the outcomes of anterior lumber interbody fusion (ALIF) with and without an "access surgeon."

SUMMARY OF BACKGROUND DATA

Anterior approaches for spine operations have become increasingly popular but may often involve unfamiliar anatomy and territory for spine surgeons, potentially placing the patient at risk to a greater proportion of approach-related complications. Thus, many spine surgeons require or prefer the assistance of an "access surgeon" to perform the exposure. However, there has been much debate about the necessity of an "access surgeon."

METHODS

A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Meta-analysis was used to pool overall rates, and compare the outcomes of ALIF with an access surgeon and without.

RESULTS

A total of 58 (8028 patients) studies were included in this meta-analysis. The overall intraoperative complications were similar with and without an "access surgeon." The overall pooled rate of arterial injuries [no access 0.44% vs. access 1.16%, odds ratio (OR) 2.67, P < 0.001], retrograde ejaculation (0.41% vs. 0.96%, OR 2.34, P = 0.005), and ileus (1.93% vs. 2.26%, OR 2.45, P < 0.001) was higher with an "access surgeon." However, the overall pooled rates of peritoneal injury (0.44% vs. 0.16%, OR 0.36, P = 0.034) and neurological injury (0.99% vs. 0.11%, OR 0.11, P < 0.001) were lower with an "access surgeon." Total postoperative complications (5.95% vs. 4.08%, OR 0.67, P < 0.001) were lower with an "access surgeon" along with prosthesis complications (1.59% vs. 0.89%, OR 0.56, P < 0.001) and reoperation rates (2.28% vs. 1.31%, OR 0.57, P < 0.001).

CONCLUSION

Compared with no access surgeon, the use of an access surgeon was associated with similar intraoperative complication rates, higher arterial injuries, retrograde ejaculation, ileus, and lower prosthesis complications, reoperation rates, and postoperative complications. In cases wherein exposure may be difficult, support from an "access surgeon" should be available.

LEVEL OF EVIDENCE

1.

Arthrodesis Rate and Patient Reported Outcomes After Anterior Lumbar Interbody Fusion Utilizing a Plasma-Sprayed Titanium Coated PEEK Interbody Implant: A Retrospective, Observational Analysis

BACKGROUND

Anterior lumbar interbody fusion (ALIF) is utilized in symptomatic spinal disc destabilization due to degenerative lumbar disc disease, isthmic and degenerative spondylolisthesis, internal disc disruption, or pseudarthrosis after non-operative treatments fail. The addition of a plasma-sprayed titanium coating (PTC) to polyether ether ketone spacers (PEEK) may reduce the rate of implant subsidence or non-union secondary to poor osseous-integration of non-coated PEEK or metal interbody systems.

METHODS

A retrospective, non-randomized, single-center chart review, evaluated the post-surgical follow-up data of patients receiving a PTC PEEK implant during single or multi-level ALIF procedures to determine the clinical efficacy and rate of arthrodesis after utilization of a coated spacer. Standard roentgenographs or computed tomography were used to identify successful arthrodesis following the ALIF procedure and longitudinal clinical improvements were determined by scores on the Visual Analog Scale (VAS) for low back and leg pain.

RESULTS

Forty-four subjects (48% male, mean=53 years) were included in this chart review. Follow-up radiology demonstrated radiographic union with bridging bone formation across the interbody space for 42/44 (96%) individuals with solid arthrodesis occurring at an average of 7.3 ± 2.3 months. Subjects demonstrated significant improvement in VAS low back pain (4.5 ± 2.4 point improvement, p=0.0001) and VAS leg pain (4.1 ± 3.3 point improvement, p=0.0001). While there was a significant reduction in the improvement of VAS low back pain of Worker's Compensation claimants as compared to other patients (3.9 ± 2.4 vs. 5.3 ± 2.1), there was no difference in VAS low back pain or leg pain when the data was stratified by gender, age, tobacco use, comorbidities, prior surgery, fusion construct length, use of supplemental posterior instrumentation, BMI, or diagnosis.

CONCLUSIONS

This study provides support that the addition of a PTC coating to a zero-profile PEEK lumbar interbody spacer facilitates rapid and stable fixation at the bone-implant interface. This facilitated osteogenesis is associated with significantly improved pain outcomes, low implant subsidence and a high definitive rate of arthrodesis. Future studies should include a prospective, randomized, controlled, multi-center approach to directly compare arthrodesis rates and clinical outcomes longitudinally between standard PEEK and biomaterial-coated PEEK interbody spacer systems.

Failed back surgery syndrome: current perspectives

The treatment of failed back surgery syndrome (FBSS) can be equally challenging to surgeons, pain specialists, and primary care providers alike. The onset of FBSS occurs when surgery fails to treat the patient's lumbar spinal pain. Minimizing the likelihood of FBSS is dependent on determining a clear etiology of the patient's pain, recognizing those who are at high risk, and exhausting conservative measures before deciding to go into a revision surgery. The workup of FBSS includes a thorough history and physical examination, diagnostic imaging, and procedures. After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modification and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations.

Mini-open Anterior Lumbar Interbody Fusion for Recurrent Lumbar Disc Herniation Following Posterior Instrumentation

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study is to evaluate, clinically and radiographically, the efficacy of mini-open retroperitoneal anterior lumbar discectomy followed by anterior lumbar interbody fusion (ALIF) for recurrent lumbar disc herniation following primary posterior instrumentation.

SUMMARY OF BACKGROUND DATA

Recurrent disc herniation following previous disc surgery occurs in 5 to 15% of cases. This is often treated by further surgical intervention where posterior approach is generally preferred. However, posterior surgery may be problematic if the initial surgery involved posterior instrumentation. An anterior approach may be indicated in these patients, and recent findings suggest that a "mini-open" procedure may have some benefits when compared with traditional open techniques and their associated morbidities.

METHODS

A total of 35 recurrent lumbar disc herniation patients (10 male, 25 female) following primary posterior instrumentation with an average age of 52.8 years (range: 34-70 yrs) who underwent the mini-open ALIF procedures between August 2001 and February 2012 were evaluated retrospectively. The ALIF was performed at the levels L4-L5 (n = 14), L5-S1 (n = 15), or both L4-L5 and L5-S1 (n = 6). Visual Analog pain Scale (VAS) and Oswestry Disability Index (ODI) together with radiological results were assessed.

RESULTS

The mean operating time, intraoperative estimated blood loss, and hospital stay were 115 minutes, 70 mL, and 6 days, respectively. No blood transfusion was needed. Transient complication was recorded in two patients. Postoperative follow-up was a minimum 24.3 months. VAS score and ODI percentage decreased significantly from 7.9 ± 0.8 and 78.8% ± 12.4% pre-operatively to 1.4 ± 0.6 and 21.7 ± 4.2% at final follow-up, respectively. There was no neurological worsening and radicular pain improved significantly compared with pre-operation in all the patients. Computed tomographic reconstruction 12 and 24 months after surgery showed bony fusion, normal position, and morphology of the fusion cage in all patients.

CONCLUSION

Mini-open retroperitoneal ALIF is an effective treatment for patients with recurrent lumbar disc herniation following primary posterior instrumentation.

LEVEL OF EVIDENCE

4.

Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

L5/S1 Fusion Rates in Degenerative Spine Surgery: A Systematic Review Comparing ALIF, TLIF, and Axial Interbody Arthrodesis

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine the fusion rate of an anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), and axial arthrodesis at the lumbosacral junction in adult patients undergoing surgery for 1- and 2-level degenerative spine conditions.

SUMMARY OF BACKGROUND DATA

An L5/S1 interbody fusion is a commonly performed procedure for pathology such as spondylolisthesis with stenosis; however, it is unclear if 1 technique leads to superior fusion rates.

MATERIALS AND METHODS

A systematic search of MEDLINE was conducted for literature published between January 1, 1992 and August 17, 2014. All peer-reviewed articles related to the fusion rate of L5/S1 for an ALIF, TLIF, or axial interbody fusion were included.

RESULTS

In total, 42 articles and 1507 patients were included in this systematic review. A difference in overall fusion rates was identified, with a rate of 99.2% (range, 96.4%-99.8%) for a TLIF, 97.2% (range, 91.0%-99.2%) for an ALIF, and 90.5% (range, 79.0%-97.0%) for an axial interbody fusion (P=0.005). In a paired analysis directly comparing fusion techniques, only the difference between a TLIF and an axial interbody fusion was significant. However, when only cases in which bilateral pedicle screws supported the interbody fusion, no statistical difference (P>0.05) between the 3 techniques was identified.

CONCLUSIONS

The current literature available to guide the treatment of L5/S1 pathology is poor, but the available data suggest that a high fusion rate can be expected with the use of an ALIF, TLIF, or axial interbody fusion. Any technique-dependent benefit in fusion rate can be eliminated with common surgical modifications such as the use of bilateral pedicle screws.

Comparison of ALIF vs. XLIF for L4/5 interbody fusion: pros, cons, and literature review

The incidence of lumbar fusion for the treatment of various degenerative lumbar spine diseases has increased dramatically over the last twenty years. Many lumbar fusion techniques have been developed and popularized, each with its own advantages and disadvantages. Anterior lumbar interbody fusion (ALIF) initially introduced in the 1930's, has become a common and widely accepted technique for lumbar fusions over the last decade offering several advantages over standard posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF). More recently, the lateral trans-psoas approach termed extreme, direct or lateral lumbar interbody fusion (XLIF, DLIF, LLIF) is gaining widespread popularity. The aim of this paper is to compare the approaches, advantages and disadvantages of ALIF and XLIF for L4/5 interbody fusion based on relevant literature.

Hidden blood loss in anterior lumbar interbody fusion (ALIF) surgery

BACKGROUND

A retrospective study was performed to determine the factors affecting the total perioperative blood loss during anterior lumbar interbody fusion (ALIF). Measurements of intraoperative blood loss underestimate the true blood loss during surgery. Our research project was to examine the hidden blood loss in lumbar spine surgery. Hidden blood loss in elective knee and hip replacement surgeries range between 100% and 30%. Hidden blood loss was about 40% in posterior spine surgery.

METHODS

The factors analyzed included gender, body mass index (BMI), duration of surgery, type of surgery, aspiration, and number of fusion levels. Estimated blood loss (EBL) was obtained from the clinical records of patients as the blood collected from suctioning and the cumulative weight of the saturated sponges. Actual blood loss (ABL) was calculated from the estimated blood volume and hemoglobin level of patients. Hidden blood loss was calculated as the difference between ABL and EBL.

RESULTS

Seventy-eight consecutive patients who underwent ALIF were reviewed. The average values (mean±SD) for EBL and ABL were 700.1±562.3mL and 1150.6±770.0mL, respectively (P=0.001, Student's t-test). The hidden blood loss averaged 39.2% of the ABL. According to linear regression analysis, surgical duration, type of surgery, and the inclusion of the L4/5 level were independent factors contributing to the ABL (P<0.05), whereas BMI and gender did not correlate with ABL or EBL.

CONCLUSIONS

ALIF is associated with substantial perioperative hidden blood loss. Length of surgery, type of surgery, and the inclusion of L4/5 in the procedure are significant risk factors for increased blood loss.

LEVEL OF EVIDENCE

Level IV: retrospective or historical series.

Anterior lumbar interbody fusion with integrated fixation and adjunctive posterior stabilization: A comparative biomechanical analysis

BACKGROUND

Interbody fusion cages with integrated fixation components have become of interest due to their ability to provide enhanced post-operative stability and mitigate device migration. A recently approved anterior lumbar interbody fusion cage with integrated fixation anchors has yet to be compared in vitro to a standard polyetheretherketone cage when used in combination with an interspinous process clamp.

METHODS

Twelve human cadaveric lumbar segments were implanted at L4-L5 with a Solus interbody cage (n=6) or standard polyetheretherketone cage (n=6) following Intact testing and discectomy. Each cage was subsequently evaluated in all primary modes of loading after supplementation with the following posterior constructs: interspinous process clamp, bilateral transfacet screws, unilateral transfacet screw with contralateral pedicle screws, and bilateral pedicle screws. Range of motion results were normalized to Intact, and a two-way mixed analysis of variance was utilized to detect statistical differences.

FINDINGS

The Solus cage in combination with all posterior constructs provided significant fixation compared to Intact in all loading conditions. The polyetheretherketone cage also provided significant fixation when combined with all screw based treatments, however when used with the interspinous process clamp a significant reduction was not observed in lateral bending or axial torsion.

INTERPRETATION

Interbody cages with integrated fixation components enhance post-operative stability within the intervertebral space, thus affording clinicians the potential to utilize less invasive methods of posterior stabilization when seeking circumferential fusion. Interspinous process clamps, in particular, may reduce peri-operative and post-operative comorbidities compared to screw based constructs. Further study is necessary to corroborate their effectiveness in vivo.

Axial interbody arthrodesis of the L5-S1 segment: a systematic review of the literature

OBJECT

The object of this study was to determine the fusion rate and safety profile of an axial interbody arthrodesis of the L5-S1 motion segment.

METHODS

A systematic search of MEDLINE was conducted for literature published between January 1, 2000, and August 17, 2014. All peer-reviewed articles related to the fusion rate of L5-S1 and the safety profile of an axial interbody arthrodesis were evaluated.

RESULTS

Seventy-four articles were identified, but only 15 (13 case series and 2 retrospective cohort studies) met the study inclusion criteria. The overall pseudarthrosis rate at L5-S1 was 6.9%, and the rate of all other complications was 12.9%. A total of 14.4% of patients required additional surgery, and the infection rate was 5.4%. Deformity studies reported a significantly increased rate of complications (46.3%), and prospectively collected data demonstrated significantly higher complication (36.8%) and revision (22.6%) rates. Lastly, studies with a conflict of interest reported lower complication rates (12.4%).

CONCLUSIONS

A systematic review of the literature indicates that an axial interbody fusion performed at the lumbosacral junction is associated with a high fusion rate (93.15%) and an acceptable complication rate (12.90%). However, these results are based mainly on retrospective case series by authors with a conflict of interest. The limited prospective data available indicate that the actual fusion rate may be lower and the complication rate may be higher than currently reported.

Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications

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 decrease 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 identify 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 invasive, 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 revision 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 associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit.

CONCLUSIONS

Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.

Imaging of lumbar spine fusion

This article reviews the imaging of lumbar spinal fusion and its major indications. The most common procedures are described for the purpose of allowing understanding of postoperative imaging. Imaging options are reviewed for preoperative workup, intraoperative guidance, and postoperative purposes. Examples of hardware integrity, fusion, and loosening are provided.

Comparing miniopen and minimally invasive transforaminal interbody fusion in single-level lumbar degeneration

Degenerative diseases of the lumbar spine, which are common among elderly people, cause back pain and radicular symptoms and lead to a poor quality of life. Lumbar spinal fusion is a standardized and widely accepted surgical procedure used for treating degenerative lumbar diseases; however, the classical posterior approach used in this procedure is recognized to cause vascular and neurologic damage of the lumbar muscles. Various studies have suggested that using the minimally invasive transforaminal interbody fusion (TLIF) technique provides long-term clinical outcomes comparable to those of open TLIF approaches in selected patients. In this study, we compared the perioperative and short-term advantages of miniopen, MI, and open TLIF. Compared with open TLIF, MI-TLIF and miniopen TLIF were associated with less blood loss, shorter hospital stays, and longer operative times; however, following the use of these procedures, no difference in quality of life was measured at 6 months or 1 year. Whether miniopen TLIF or MI-TLIF can replace traditional TLIF as the surgery of choice for treating degenerative lumbar deformity remains unclear, and additional studies are required for validating the safety and efficiency of these procedures.

Comparison of the different surgical approaches for lumbar interbody fusion

This review will outline the history of spinal fusion. It will compare the different approaches currently in use for interbody fusion. A comparison of the techniques, including minimally invasive surgery and graft options will be included. Lumbar interbody fusion is a commonly performed surgical procedure for a variety of spinal disorders, especially degenerative disease. Currently this procedure is performed using anterior, lateral, transforaminal and posterior approaches. Minimally invasive techniques have been increasing in popularity in recent years. A posterior approach is frequently used and has good fusion rates and low complication rates but is limited by the thecal and nerve root retraction. The transforaminal interbody fusion avoids some of these complications and is therefore preferable in some situations, especially revision surgery. An anterior approach avoids the spinal cord and cauda equina all together, but has issues with visceral exposure complications. Lateral lumbar interbody fusion has a risk of lumbar plexus injury with dissection through the psoas muscle. Studies show less intraoperative blood loss for minimally invasive techniques, but there is no long-term data. Iliac crest is the gold standard for bone graft, although adjuncts such as bone morphogenetic proteins are being used more frequently, despite their controversial history. More high-level studies are needed to make generalisations regarding the outcomes of one technique compared with another.

Mini-open approach for direct lateral lumbar interbody fusion

Study Design

Retrospective analysis.

Purposes

To introduce the mini-open lateral approach for the anterior lumbar interbody fusion (ALIF), and to investigate the advantages, technical pitfalls and complications by providing basic knowledge on extreme lateral interbody fusion (XLIF) or direct lumbar interbody fusion (DLIF).

Overview of Literature

Recently, minimally invasive lateral approach for the lumbar spine is revived and receiving popularity under the name of XLIF or DLIF by modification of mini-open method when using the sequential tubular dilator and special expandable retractor system.

Methods

Seventy-four patients who underwent surgery by the mini-open lateral approach from September 2000 to April 2008 with various disease entities were included. Blood losses, operation times, incision sizes, postoperative time to mobilization, length of hospital stays, technical problems and complications were all analyzed.

Results

The blood losses and operation times of patients who underwent simple ALIF were 61.2 mL and 86 minutes for one level, 107 mL and 106 minutes for two levels, 250 mL and 142.8 minutes for three levels, and 400 mL and 190 minutes for four levels of fusion. The incision sizes were on average 4.5 cm for one level, 6.3 cm for two levels, 8.5 cm for three levels and 10.0 cm for four levels of fusion. The complications were retroperitoneal hematoma (2 cases), pneumonia (1 case) and transient lumbosacral plexus palsy (3 cases).

Conclusions

Trials of mini-open lateral approach would be helpful before the trial of XLIF or DLIF. However, special attention is required for complications such as transient lumbosacral plexus palsy.

Large blood vessel stretch in lumbar spine through anterior surgical approach: An experimental study in adult goat

BACKGROUND

Various anterior lumbar surgical approaches, including the minimally invasive approach, have greatly improved in recent years. Vascular complications resulting from ALIF are frequently reported. Little information is available about the safety of large blood vessel stretch. We evaluated the right side stretch limit (RSSL) of the abdominal aorta (AAA) and the inferior vena cava (IVC) without blood flow occlusion and investigated stretch-induced histological injury and thrombosis in the iliac and femoral arteries and veins and the stretched vessels.

MATERIALS AND METHODS

The RSSL of blood vessels in five adult goats was measured by counting the number of 0.5-cm-thick wood slabs that were inserted between the right lumbar edge and the stretch hook. Twenty seven adult goats were divided into three groups to investigate histological injury and thrombosis under a stretch to 0.5 cm (group I) 1.5 cm (group II) for 2 h, or no stretch (group III). Blood vessel samples from groups I and II were analyzed on postsurgical days 1, 3, and 7. Thrombogenesis was examined in the iliac and femoral arteries and veins.

RESULTS

The RSSL of large blood vessels in front of L4/5 was 1.5 cm from the right lumbar edge. All goats survived surgery without complications. No injury or thrombosis in the large blood vessels in front of the lumbar vertebrae and in the iliac or femoral arteries and veins was observed. Under light microscopy, group I showed slight swelling of endothelial cells in the AAA and no histological injury of the IVC. The AAA of group II showed endothelial cell damage, unclear organelles, and incomplete cell connections by electron microscopy.

CONCLUSIONS

The AAA and IVC in a goat model can be stretched by ≤0.5 cm, with no thrombosis in the AAA, IVC, iliac or femoral arteries and veins.

Surgical management of minimally invasive anterior lumbar interbody fusion with stand-alone interbody cage for L4-5 degenerative disorders: clinical and radiographic findings

Surgical treatment for degenerative spinal disorders is controversial, although lumbar fusion is considered an acceptable option for disabling lower back pain. Patients underwent instrumented minimally invasive anterior lumbar interbody fusion (mini-ALIF) using a retroperitoneal approach except for requiring multilevel fusions, severe spinal canal stenosis, high-grade spondylolisthesis, and a adjacent segments disorders. We retrospectively reviewed the clinical records and radiographs of 142 patients who received mini-ALIF for L4-5 degenerative lumbar disorders between 1998 and 2010. We compared preoperative and postoperative clinical data and radiographic measurements, including the modified Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back and leg pain, disc height (DH), whole lumbar lordosis (WL), and vertebral wedge angle (WA). The mean follow-up period was 76 months. The solid fusion rate was 90.1% (128/142 patients). The average length of hospital stay was 6.9 days (range, 3–21 days). The mean blood loss was 63.7 ml (range, 10–456 ml). The mean operation time was 155.5 min (range, 96–280 min). The postoperative JOA and VAS scores for back and leg pain were improved compared with the preoperative scores. Radiological analysis showed significant postoperative improvements in DH, WL, and WA, and the functional and radiographical outcomes improved significantly after 2 years. The 2.8% complication rate included cases of wound infection, liquorrhea, vertebral body fractures, and a misplaced cage that required revision. Mini-ALIF was found to be associated with improved clinical results and radiographic findings for L4-5 disorders. A retroperitoneal approach might therefore be a valuable treatment option.

Long-term 2- to 5-year clinical and functional outcomes of minimally invasive surgery for adult scoliosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

We assess MIS technique's clinical and functional outcomes during a 2- to 5-year period.

SUMMARY OF BACKGROUND DATA

Traditional surgical approaches for adult scoliosis are associated with significant blood loss and morbidity, in a population that is often elderly with multiple medical comorbidities. Minimally invasive surgery (MIS) represents a newer method of achieving similar long-term outcomes but considerably lower morbidity and complication rates.

METHODS

We reviewed 71 patients who underwent MIS correction of spinal deformity with fusion of 2 or more levels including: degenerative scoliosis (54), idiopathic scoliosis (11), and iatrogenic scoliosis (6). All underwent a combination of 3 MIS techniques: direct lateral interbody fusion (66), axial lumbar interbody fusion (34), and posterior instrumentation (67). Thirty-six patients were staged with direct lateral interbody fusion done first followed by the posterior instrumentation and fusion including axial lumbar interbody fusion done 3 days later.

RESULTS

Mean age was 64 years (20-84 yr). Mean follow-up was 39 months (24-60 mo). Patients with 1-stage same-day surgery had a mean blood loss of 412 mL and a mean surgical time of 291 minutes. Patients with 2-stage surgery had a mean blood loss of 314 mL and surgical time of 183 minutes for direct lateral interbody fusion and 357 mL and 243 minutes, respectively for posterior instrumentation and axial lumbar interbody fusion. Mean hospital stay was 7.6 days (2-26 d). The mean preoperative Cobb angle was 24.7° (8.3°-65°), which corrected to 9.5° (0.6°-28.8°). Mean preoperative Coronal balance was 25.5 mm, which corrected to 11 mm. Mean preoperative sagittal balance was 31.7 mm and corrected to 10.7 mm. The mean preoperative lumbar apical vertebral translation was 24 mm and corrected to 12 mm. Fourteen patients had adverse events requiring intervention: 4 pseudarthrosis, 4 persistent stenosis, 1 osteomyelitis, 1 adjacent segment discitis, 1 late wound infection, 1 proximal junctional kyphosis, 1 screw prominence, 1 idiopathic cerebellar hemorrhage, and 2 wound dehiscence.

CONCLUSION

A combination of 3 novel MIS techniques allows comparable correction of adult spinal deformity, with low pseudarthrosis rates, significantly improved functional outcomes, and excellent clinical and radiological improvement, but considerably lowers morbidity and complication rates at early and long-term follow-up.

Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients

PURPOSE

The main aim of this paper was to report reproducible method of lumbar spine access via a lateral retroperitoneal route.

METHODS

The authors conducted a retrospective analysis of the technical aspects and clinical outcomes of six patients who underwent lateral multilevel retroperitoneal interbody fusion with psoas muscle retraction technique. The main goal was to develop a simple and reproducible technique to avoid injury to the lumbar plexus.

RESULTS

Six patients were operated at 15 levels using psoas muscle retraction technique. All patients reported improvement in back pain and radiculopathy after the surgery. The only procedure-related transient complication was weakness and pain on hip flexion that resolved by the first follow-up visit.

CONCLUSIONS

Psoas retraction technique is a reliable technique for lateral access to the lumbar spine and may avoid some of the complications related to traditional minimally invasive transpsoas approach.

Safe zone for retractor placement to the lumbar spine via the transpsoas approach

PURPOSE

To measure anatomic variations of the lumbar plexus within the psoas in relation to the L2/3, L3/4, and L4/5 disc spaces and to delineate a safe zone to avoid nerve injury during retractor placement via the transpsoas approach.

METHODS

Six male and 6 female cadavers (24 psoas/ lumbar plexuses) aged 35 to 74 years were dissected. The lumbar plexus was isolated bilaterally. The L2, L3, and L4 nerve roots were identified and isolated without disturbing their natural anatomic course. The anteroposterior (AP) diameter of each intervertebral disc at L2/3, L3/4, and L4/5 was used as a reference. Four measurements were made using a caliper: the AP and mediolateral (ML) diameters of the psoas and AP and ML excursions of each nerve root. Percentages were calculated for the 4 measurements using the reference of the AP diameter of the intervertebral disc at each level. Comparison between left and right sides, between males and females, and between excursions of nerve roots were made.

RESULTS

The AP diameter of the psoas increased from L2 to L4, with a mean vertebral body coverage of 80%, 86%, and 85% at L2/3, L3/4, and L4/5, respectively. Both the L2 and L3 nerve roots demonstrated substantial anterior trajectories as they coursed distally in the lumbar spine. No nerve root encroached anteriorly beyond 33% of the intervertebral disc space at L2 to L5.

CONCLUSION

The lumbar plexus area corresponding to the anterior half of the intervertebral disc was the safe zone. Procedures to the lumbar spine via the transpsoas approach should be performed within the safe zone to avoid nerve injury.

Urological injury as a complication of the transpsoas approach for discectomy and interbody fusion

Transpsoas discectomy and interbody fusion has become an increasingly popular method of achieving lumbar interbody fusion, but reports of neurological, vascular, and gastrointestinal complications associated with this procedure have been described in the literature. To date, however, ureteral complications have not been reported with this procedure. The authors report 2 cases of ureteral injury and 1 case of renal injury following this procedure. A low index of suspicion is warranted to work up any patient having flank or abdominal symptoms after undergoing transpsoas discectomy and interbody fusion.

Allograft cellular bone matrix in extreme lateral interbody fusion: preliminary radiographic and clinical outcomes

Introduction. Extreme lateral interbody fusion (XLIF) is a minimally disruptive alternative for anterior lumbar interbody fusion. Recently, synthetic and allograft materials have been increasingly used to eliminate donor-site pain and complications secondary to autogenous bone graft harvesting. The clinical use of allograft cellular bone graft has potential advantages over autograft by eliminating the need to harvest autograft while mimicking autograft's biologic function. The objective of this study was to examine 12-month radiographic and clinical outcomes in patients who underwent XLIF with Osteocel Plus, one such allograft cellular bone matrix. Methods. Forty (40) patients were treated at 61 levels with XLIF and Osteocel Plus and included in the analysis. Results. No complications were observed. From preoperative to 12-month postoperative followup, ODI improved 41%, LBP improved 55%, leg pain improved 43.3%, and QOL (SF-36) improved 56%. At 12 months, 92% reported being “very” or “somewhat” satisfied with their outcome and 86% being either “very” or “somewhat likely” to choose to undergo the procedure again. Complete fusion was observed in 90.2% (55/61) of XLIF levels. Conclusions. Complete interbody fusion with Osteocel Plus was shown in 90.2% of XLIF levels, with the remaining 9.8% being partially consolidated and progressing towards fusion at 12 months.