Anterior Lumbar Interbody Fusion in Left-sided Inferior Vena Cava and Right-sided Aortic Arch

Venous Anomalies Complicating Anterior Lumbar Interbody Fusion Exposures

The effects of anomalous vasculature impeding optimal exposure to an anterior lumbar interbody fusion approach are limited in literature. We present five individual, unique cases of vascular anomalies in patients undergoing two-stage anterior-posterior lumbar interbody fusion. Cases 1, 2, 4, and 5 have yet to be described in literature in context of anterior lumbar interbody fusions. Case 3 presents anomalous vasculature that has only been described in two other case reports. Case 1 presents the right internal iliac vein originating from the left common iliac vein which was transected for L4-L5 vertebral disc exposure. Case 2 presents the left internal iliac vein originating from the right common iliac vein which required an oblique approach. Case 3 presents a duplicated inferior vena cava that was taken into account but did not interfere with the anterior retroperitoneal approach. Case 4 presents large osteophytes adhering to the left common iliac vein which limited safe dissection and mobilization. Case 5 presents the left internal iliac vein with a high takeoff spanning across the L5-S1 vertebral disc space and requiring transection. This case series highlights the need for preoperative imaging and a working detailed knowledge of anatomy to avoid damaging vasculature that can potentially lead to fatal consequences. The information given in this case series should inform both spine and vascular surgeons on proper preoperative planning. To maximize operative efficiency and safety, spine surgeons and vascular surgeons should collaborate to minimize surgical complications.

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.

The lumbar autonomic nerves in males: a few anatomical insights into anterior lumbar interbody fusion

BACKGROUND CONTEXT

Lumbar autonomic nerve injury is an underappreciated complication of anterior lumbar spinal surgery. A detailed description of lumbar autonomic nerve anatomy would be helpful for surgeons to minimize the risk of this complication.

PURPOSE

This study was designed to investigate the anatomical characteristics of lumbar autonomic nerves and provide a better understanding of these nerves for anterior lumbar spinal surgery.

STUDY DESIGN

A dissection-based study of 10 embalmed male cadavers.

METHODS

The lumbar autonomic nerves from 10 embalmed male cadavers were dissected in this study. The position of the lumbar sympathetic trunks was recorded. Distance between the initial sites of the lumbar splanchnic nerves (LSNs) and the corresponding lumbar vertebral inferior endplate, distance between the ipsilateral and adjacent LSNs, angles formed by the LSNs and the vertical axis were measured. This study has been supported by grants from Science and Technology Planning Project of Guangdong Province (CN) (Grant No. 2017B020210010) without potential conflict of interest-associated biases in the text of the paper.

RESULTS

In this study, a total of 72 LSNs were identified in the 10 human cadavers. On average, the investigation found that the initial sites of the first, second, third, and fourth LSNs were 9 mm distal, 5 mm distal, 9 mm proximal, and 9 mm distal to the inferior endplates of the L1, L2, L3, and L4 vertebrae, respectively, with variations from 6 to 11 mm for each nerve among specimens. There was no significant difference in the angle between each lumbar splanchnic nerve and the vertical axis (H=2.461, p=.482), with an angle of approximately 50°±6°. The distance between the first and the second LSNs, the second and the third LSNs, or the third and the fourth LSNs were 24±6 mm, 22±8 mm, and 55±11 mm, respectively. The bilateral lumbar sympathetic trunks (N=57, 95%) were more likely to be located in the first third of the sagittal plane at the level of the L2/3, L3/4, and L4/5 intervertebral discs.

CONCLUSIONS

The study found the same number and parallel courses of LSNs on each side, and on both the left and right side, the distance between the third and the fourth LSNs was much larger than the distance between the other two adjacent LSNs. The initial sites of 80.6% (n=58) of LSNs were superior to the inferior endplate of the L3 vertebra. Improved knowledge of lumbar autonomic nerve anatomy may be of great significance in reducing complications and improving surgical safety.

Two level Anterior Lumbar Interbody Fusion (ALIF) in a patient with a rare vascular malformation, a duplication of the inferior vena cava

BACKGROUND

Anterior Lumbar Interbody Fusion is now a well-established procedure to treat degenerative lumbar disease. This approach has its own risks and each spine surgeon must understand the pitfalls that can be encountered when dealing with an anatomy variation of the vessels in order to be able to perform the safest possible procedure.

CASE DESCRIPTION

We report the case of a 48 years old man with a rare vascular anatomy variation undergoing a two-levels L4-L5 and L5-S1 ALIF procedure through a right-sided retroperitoneal approach. The preoperative imaging planning revealed a duplication of the Inferior Vena Cava (IVC) located on each side of the aorta.

CONCLUSION

Preoperative Imaging evaluation and a detailed knowledge of the anatomy is the key of a safe and successful procedure as any variation can complicate the anterior approach. We believe that teaming up with a vascular surgeon for junior surgeons during the first anterior procedures and especially in the context of anatomical variation is recommended.