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

Clinical and Radiographic Outcomes of Anterior Lumbar Interbody Fusions Using a Titanium Cage with a Biomimetic Surface

BACKGROUND

 We analyzed clinical and radiographic outcomes in patients undergoing anterior lumbar interbody fusions (ALIFs) using a new biomimetic titanium fusion cage (Titan nanoLOCK interbody, Medtronic, Minneapolis, Minnesota, United States). This specialized cage employs precise nanotechnology to stimulate inherent biochemical and cellular osteogenic reactions to the implant, aiming to amplify the rate of fusion. To our knowledge, this is the only study to assess early clinical and radiographic results in ALIFs.

METHODS

 We conducted a retrospective review of data for patients who underwent single or multilevel ALIF using this implant between October 2016 and April 2021. Indications for treatment were spondylolisthesis, postlaminectomy syndrome, or spinal deformity. Clinical and radiographic outcome data for these patients were collected and assessed.

RESULTS

 A total of 84 patients were included. The mean clinical follow-up was 36.6 ± 14 months. At 6 months, solid fusion was seen in 97.6% of patients. At 12 months, solid fusion was seen in 98.8% of patients. Significant improvements were seen in patient-reported outcome measures (PROMs; visual analog scale and Oswestry Disability Index) at 6 and 12 months compared with the preoperative scores (p < 0.001). One patient required reoperation for broken pedicle screws 2 days after the ALIF. None of the patients required readmission within 90 days of surgery. No patients experienced an infection.

CONCLUSIONS

 ALIF using a new titanium interbody fusion implant with a biomimetic surface technology demonstrated high fusion rates (97.6%) as early as 6 months. There was significant improvement in PROMs at 6 and 12 months.

Lumbar disc herniation: Prevention and treatment of recurrence: WFNS spine committee recommendations

Objective

This review aims to formulate the most current evidence-based recommendations on the epidemiology, prevention, and treatment of recurrent lumbar disc herniation (LDH).

Methods

We performed a systematic literature search in PubMed, Medline, and Google Scholar databases from 2012 to 2022 using the keywords "lumbar disc recurrence." Screening criteria resulted in 57 papers, which were summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The 57 papers covered the following topics: (1) Definition and incidence of recurrence after lumbar disc surgery; (2) Prediction of recurrence before primary surgery; (3) Prevention of recurrence by surgical measures; (4) Prevention of recurrence by postoperative measures; (5) Treatment options for recurrent disc herniation; (6) The outcomes of recurrent disc herniation surgery. We utilized the Delphi method and voted on eight final consensus statements.

Results and conclusion

Recurrence after disc herniation surgery may be considered a surgical complication, its incidence is approximately 5% and is different from overall re-operation incidence. There are multiple risk factors predicting LDH recurrence, including smoking, younger age, male gender, obesity, diabetes, disc degeneration, and presence of lumbosacral transitional vertebrae. The level of lumbar discectomy surgery and the amount of disc material removed do not correlate with recurrence rate. Minimally invasive discectomies may have higher recurrence rates, especially during the surgeon's learning period. However, the experience of the surgeon is not related to recurrence. High-quality studies are needed to determine if activity restriction, weight loss, smoking cessation, and muscle-strengthening exercises after primary surgery can help prevent recurrence of LDH.The best treatment option for recurrent disc herniation is still being discussed. While complications of minimally invasive techniques may be lower than open discectomy, outcomes are similar. Fusion should only be considered when spinal instability and/or spinal deformity are present. Clinical outcomes and patient satisfaction after recurrent disc herniation surgery are inferior to those after initial discectomy.

Spinal Fusion Versus Repeat Discectomy for Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

OBJECTIVE

Recurrent lumbar disc herniation (RLDH) is one of the major causes of failure for primary surgery. Repeat discectomy (RD) and spinal fusion (SF) are 2 surgical options for RLDH. The objective of our study is to compare the effectiveness of SF compared with RD in the treatment of RLDH.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Ovid Medline for studies (published between Jan 1, 1959 and July 8, 2022; no language restriction) comparing SF and RD for the RLDH. Odds ratio and weighted mean difference were calculated for binary outcomes and continuous outcomes. The quality of each outcome was graded using the Grading of Recommendations, Assessment, Development and Evaluations criteria.

RESULTS

We identified 5029 studies, of which 11 studies were included. There were 2 randomized controlled trials and the remaining were observational studies. Comparing SF and RD groups, no differences were found in visual analog scales for leg and back and Oswestry Disability Index. Furthermore, the Japanese Orthopaedic Association scores of SF were significantly higher than the RD group. In terms of complications, the incidence of neurological deficit, segmental instability, and re-recurrence is significantly lower with SF than with the RD group. Lastly, the SF group was associated with longer hospital stays and operation time, and more blood loss.

CONCLUSIONS

The pooled evidence suggests that fusion achieves better results than RD for RLDH. The results of this review should be further confirmed by future high-quality randomized controlled trials.

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.

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.

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.

Predictors of inpatient admission in the setting of anterior lumbar interbody fusion: a Minimally Invasive Spine Study Group (MISSG) investigation

OBJECTIVE

While the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications have hindered transition of this procedure to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of ≥ 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist in the development of screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting for this procedure. The purpose of this study was to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF.

METHODS

A prospectively maintained surgical registry was reviewed for patients undergoing single ALIF between May 2006 and December 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their relative risk (RR) elevation for an inpatient stay of ≥ 24 hours. A Poisson regression model was used to evaluate predictors of inpatient stays of ≥ 24 hours. Risk factors for inpatient admission of ≥ 24 hours were identified with a stepwise backward regression model.

RESULTS

A total of 111 patients underwent single-level ALIF (50.9% female and 52.6% male, ≤ 50 years old). Eleven (9.5%) patients were discharged in < 24 hours and 116 remained admitted for ≥ 24 hours. The average inpatient stay was > 2 days (53.7 hours). The most common postoperative complications were fever (body temperature ≥ 100.4°F; n = 4, 3.5%) and blood transfusions (n = 4, 3.5%). Bivariate analysis revealed a preoperative diagnosis of retrolisthesis or lateral listhesis to elevate the RR for an inpatient stay of ≥ 24 hours (RR 1.11, p = 0.001, both diagnoses). Stepwise multivariate analysis demonstrated significant predictors for inpatient stays of ≥ 24 hours to be an operation on L4-5, coexisting degenerative disc disease (DDD) with foraminal stenosis, and herniated nucleus pulposus (RR 1.11, 95% CI 1.03-1.20, p = 0.009, all covariates).

CONCLUSIONS

This study provides data regarding the incidence of demographic and perioperative characteristics and postoperative complications as they pertain to patients undergoing single-level ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients.

Risk Factors and Surgical Treatment for Recurrent Lumbar Disc Prolapse: A Review of the Literature

We aim to present the current evidence on various risk factors and surgical treatment modalities for recurrent lumbar disc herniation (rLDH). Using PubMed, a literature search was performed using the Mesh terms "recurrent disc prolapse," "herniated lumbar disc," "risk factors," and "treatment." Articles that were published between January 2010 and May 2017 were selected for further screening. A search conducted through PubMed identified 213 articles that met the initial screening criteria. Detailed analyses showed that 34 articles were eligible for inclusion in this review. Sixteen articles reported the risk factors associated with rLDH. Decompression alone as a treatment option was studied in seven articles, while 11 articles focused on different types of fusion surgery (anterior lumbar interbody fusion, posterior lumbar interbody fusion, open transforaminal lumbar interbody fusion [TLIF], and minimally invasive surgery-TLIF). Management of the rLDH requires consideration of the possible risk factors present in individual patients before primary and at the time of second surgery. Both, minimally invasive and conventional open procedures are comparably effective in relieving leg pain, and minimally invasive techniques offer advantage over the other technique in terms of tissue sparing. Non-fusion surgeries involve the risk of lumbar disc herniation re-recurrence, and the patient may require a third (fusion) surgery.

Lumbar Disc Herniation Within Solid Fused Segments After Removal of Pedicle Screws: A Case Report

CASE

A 73-year-old man with instrumented fusion of L3-4-5 underwent the removal of previous pedicle screws and posterior instrumented fusion of L1-2-3. The solid dorsal fusion mass of L3-5 was identified intraoperatively and preoperatively. At 3 years after the second surgery, he presented with abrupt radiating pain in the left leg. Plain radiographs showed a collapse of the intervertebral disc space, and magnetic resonance imaging showed disc herniation of L3-4.

CONCLUSIONS

Disc herniation even in solid fused segments may occur. Removal of pedicle screws and cranial extension of interbody fusion may increase the intradiscal stress associated with physiologic cantilever motion of the disc.

Postoperative direct health care costs of lumbar discectomy are reduced with the use of a novel annular closure device in high-risk patients

BACKGROUND CONTEXT

Lumbar discectomy is largely successful surgical procedure; however, reherniation rates in patients with large annular defects are as high as 27%. The expense associated with a revision surgery places significant burden on the healthcare system.

PURPOSE

To compare the direct health care costs through 5 years follow-up of conventional discectomy (Control) with those of discectomy supplemented by an adjunctive annular closure device (ACD) in high-risk patients with large annular defects.

STUDY DESIGN

This was a cost-effectiveness study.

METHODS

All-cause index level reoperations were reviewed from a multicenter, randomized controlled superiority trial that allocated 554 high-risk discectomy patients with large annular defects to either control or ACD. Medicare and private insurer (Humana) direct costs were derived from a commercially available payer database to estimate costs in the US healthcare system, including those associated with facility, surgeon, imaging, follow-up visits, physical therapy, and injections. A 50:50 split between Medicare and commercial insurers was assumed for the base case analysis. The analysis was also performed on a 80:20 commercial:Medicare payer basis. For the base case scenario, a 2-year time horizon and outpatient cost setting was established for the index procedure. Repeat discectomy was assumed to be performed on a 60:40 outpatient-to-inpatient basis. Complications requiring surgery, revisions, and/or fusion were assumed to be managed in the inpatient setting. Total costs of reoperation and per-patient costs of reoperation were compared between groups for both forms of insurers. One author received consulting fees of <$50,000 for the completion of this study, and the other eight authors did not have any financial associations with the current work. Funding for this study was provided by Intrinsic Therapeutics, but all analyses, interpretation, and writing were performed independently by the authors.

RESULTS

At two years follow-up, use of the ACD reduced the rate of symptomatic reherniations in a large defect population to 13% compared with 25% in the control group (p<.001). This reduction in symptomatic reherniations in the ACD group translated to a savings of $2,802 per patient in direct health care costs compared with Control at 2 years and $5,315 per patient by 5 years based on 50% private and 50% public (Medicare) payer split. Under the scenario of 80:20 private:public insurance reimbursement, the estimated direct cost savings were $3,215 and $6,099 per patient at 2- and 5-years postoperatively, respectively, with the use of the ACD.

CONCLUSIONS

Symptomatic reherniation and reoperation rates were nearly double among control patients compared with ACD-treated patients, which translated to markedly greater per-patient healthcare costs in the control group, where the ACD was not used.

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.

Anterior lumbar interbody fusion (ALIF) as an option for recurrent disc herniations: a systematic review and meta-analysis

Background

Recurrent intervertebral disc herniation is a relatively common occurrence after primary discectomy for lumbar intervertebral disc herniation. For recurrent herniations after repeat discectomies, a growing body of evidence suggests that fusion is effective in appropriately selected cases. Theoretically, anterior lumbar interbody fusion (ALIF) allows for comprehensive discectomy, less trauma to spinal nerves and paraspinal muscles and avoidance of the disadvantages of repeat posterior approaches. However, ALIF has also been associated with risk of vascular injury and retrograde ejaculation. This current systematic review and meta-analysis aims to assess the viability of ALIF as a surgical treatment for recurrent disc herniations.

Methods

Seven studies were identified from six electronic databases and secondary reference lists. Pre-defined endpoints were extracted from the included studies and meta-analyzed.

Results

For the 181 patients from included studies, ALIF resulted in significant average improvements in Oswestry Disability Index (ODI) scores (50.49%, P<0.001), Visual Analogue Scale (VAS) back pain scores (47.85%, P<0.001) and VAS leg pain scores (37.00%, P<0.001). Average blood loss was acceptable at 122 mL (P<0.001) and average operation duration was 89 minutes (P<0.001). Average hospital stay was 5.28 days (P<0.001). Only 22 perioperative complications were reported, with subsidence the most commonly reported complication.

Conclusions

Pooled evidence suggests that ALIF is a feasible approach for the treatment of recurrent disc herniations, demonstrating significant improvements in back and leg pain and minimal complications. These findings warrant further investigation in large prospective registries and multi-center studies.

Treatment for Recurrent Lumbar Disc Herniation

PURPOSE OF REVIEW

Recurrent lumbar disc herniation (RLDH) is the most common indication for reoperation after a lumbar discectomy. The purpose of this manuscript is to review the incidence, risk factors, and treatment for RLDH.

RECENT FINDINGS

Patients who require revision surgery for RLDH improved significantly compared to baseline; however, the magnitude of improvement is less than in primary discectomy patients. Treatment with either repeat discectomy or instrumented fusion has comparable clinical outcomes. Repeat discectomy patients, however, have shorter operative times and length of stay. Hospital charges are dramatically lower for repeat discectomy compared to instrumented fusion. The incidence of RLDH is somewhere between 5 and 18%. Risk factors include younger age, lack of a sensory or motor deficit, and a higher baseline Oswestry Disability Index (ODI) score. Available evidence suggests that some patients may respond to nonoperative interventions and avoid the need for reoperation. For those that fail a trial of conservative management or present with neurologic deficit, both repeat lumbar discectomy and instrumented fusion appear to effectively treat patients with similar complication rates and clinical outcomes.

Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up

PURPOSE

To compare the therapeutic efficacy of radiofrequency target disc decompression(TDD) and nucleoplasty for lumbar disc herniation.

METHODS

Two hundred sixty patients with lumbar disc herniation were divided into two groups: target disc decompression group (group T, n = 147) and nucleoplasty group (group N, n = 113). Visual analogue scale (VAS) and functional rating index (FRI) were measured at one, three, six, 12, 24, and 60 months after the surgery. Hospitalization time, operation time, complications, and recurrence/invalid were compared between the two groups.

RESULTS

Compared with the pre-operation, the VAS and FRI in both groups were significantly decreased in post-operation(P < 0.01). The VAS and FRI in group T have no significant difference compared to those in group N. The hospitalization and operation time of group T were significantly longer than those in group N. There was no significant difference of the occurrence of complications and disease recurrence/invalid during the follow-up between the two groups. Logstic regression analysis showed that operation time was an independent factor in the prognosis. Operation time affects the treatment effect. Shorter operation time leads to better therapeutic efficacy, and longer operation time leads to poor therapeutic efficacy.

CONCLUSIONS

Both TDD and nucleoplasty can reduce pain in patients with lumbar disc herniation and improve quality of life. Group N had shorter hospitalization and operation time than group T.

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.

Applying the Mini-Open Anterolateral Lumbar Interbody Fusion with Self-Anchored Stand-Alone Polyetheretherketone Cage in Lumbar Revision Surgery

The author retrospectively studied twenty-two patients who underwent revision lumbar surgeries using ALLIF with a self-anchored stand-alone polyetheretherketone (PEEK) cage. The operation time, blood loss, and perioperative complications were evaluated. Oswestry disability index (ODI) scores and visual analog scale (VAS) scores of leg and back pain were analyzed preoperatively and at each time point of postoperative follow-up. Radiological evaluation including fusion, disc height, foraminal height, and subsidence was assessed. The results showed that the ALLIF with a self-anchored stand-alone PEEK cage is safe and effective in revision lumbar surgery with minor surgical trauma, low access-related complication rates, and satisfactory clinical and radiological results.