Outcomes and complications of the midline anterior approach 3 years after lumbar spine surgery

Prospective Analysis of Incisional Morbidity Associated With Anterior Surgical Approaches to the Lumbar Spine

OBJECTIVE

Anterior approaches to the lumbar spine have been used extensively for various indications but they are also associated with unique complications and have been linked with higher incisional morbidity.This study aimsto evaluate incisional morbidity related to anterior lumbar surgeries and to assess how incisional outcomes correlate with patient and surgery-related factors.

METHODS

Patients ≥18 years old and with planned anterior lumbar fusions from L1 to S1 were prospectively enrolled. Follow-up ended at two years, and patients who did not complete the follow-up were excluded. Incision was assessed for general appearance, width, color, cross-hatching, hypertrophy, and pain by using a validated scoring system and a visual analog scale (VAS). Patient and surgery-related factors were analyzed for possible correlations with complications or wound-related parameters.

RESULTS

A total of 205 patients with a mean age of 54.4 ± 11.5 were included. Significant improvements were seen in color, hypertrophy, pain, and appearance of the incision. At two years, the mean patient-based VAS for appearance was 8.6 while surgeon-based VAS was 8.8. The total rate of complications was 9%, with no incisional hernia or bulging. No significant relation was found between incision-related parameters and the demographic and surgical variables.

CONCLUSION

This study reports acceptable cosmetic results and no chronic pain after anterior lumbar surgery, which is contrary to previous reports. Together with a low total rate of complications, anterior approaches are safe when carefully executed, and have low morbidity.

Discussing sexual health with patients eligible for spine surgery: An online survey in spine surgeon and pain physicians

Introduction

Spinal pain syndromes have a severe impact on the patient's sex life, contributing to a decrease in sexual function and sexual satisfaction. Despite the importance of sexual health on mental and physical wellbeing, sexual health is rarely discussed during consultations.

Research question

The aim of this study is to explore to what extent influencing factors can alter the discussion about sexual health during consultations. More specifically, we will evaluate the influence of healthcare profession, sex of the patient and the surgical approach that is proposed.

Material and methods

An online survey was sent to neurosurgeons, pain physicians and orthopedists in Belgium and The Netherlands in April 2019. Participants were asked about; counseling routine, knowledge, and opinion on sexual health. Answers were scored on a 5-point Likert scale. Independence between the response levels and type of surgery as well as profession were tested.

Results

In total, 350 respondents were approached of whom 57 completed the survey. The majority of respondents (61.4%) indicated that they rarely or never discussed sexual disturbances. Profession and type of surgery had an influence on discussing erectile dysfunction, retrograde ejaculation, and alterations in orgasms. Thirty-five percent of healthcare providers considered it the patient's responsibility to bring up the subject of sexual health.

Discussion and conclusion

Sexual health is rarely addressed by healthcare providers during spinal care. Profession as well as type of surgery seems to play a role on whether sexual health is discussed during consultations.

Retrograde ejaculation following anterior lumbar surgery: a systematic review and pooled analysis

OBJECTIVE

The present systematic review and pooled analysis aims to assess the incidence and risk factors for the development of retrograde ejaculation (RE) following first-time open anterior lumbar surgery.

METHODS

A systematic MEDLINE review via PubMed was performed, identifying 130 clinical papers relating to the topic. Eighteen publications were selected according to predetermined inclusion and exclusion criteria and were used to determine the incidence of RE. Only the publications that provided data on surgical risk factors present specifically in the men in the study were included in the analysis of risk factors.

RESULTS

Of the 2503 men included, there were 57 reported events of RE (2.3%). Of the cases for which long-term data were provided, 45.8% had resolved by final follow-up. There was a statistically significant increased risk associated with a transperitoneal as opposed to a retroperitoneal approach (8.6% vs 3.2%), as well as with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) as opposed to ALIF with bone graft or arthroplasty in controls (5.0% vs 1.8%). However, when excluding from analysis the patients operated on prior to the FDA's 2008 warning that commented on the drug's neuroinflammatory properties, there was no significant difference in rates of RE in patients receiving rhBMP-2 versus the control group (2.4% vs 2.5%). There was no significant difference in risk based on single- versus multilevel procedure or on ALIF versus arthroplasty.

CONCLUSIONS

In a pooled analysis of currently published data on men undergoing first-time open anterior lumbar surgery, this study found an overall incidence of RE of 2.3%. Nearly half of these patients recovered, reporting resolution of symptoms anywhere between 3 months and 48 months. Analysis of risk factors was limited by a paucity of published literature segregating data by sex. However, there was an increased risk associated with rhBMP-2 only when including data collected prior to the FDA warning on its detrimental properties. The authors therefore posit that the risk of RE is probably overestimated in the literature, given that the vast majority of the data available were collected prior to this warning and given the subsequent implementation of precautions when handling rhBMP-2.

Extraforaminal L5 Nerve Root Compression Caused by Intervertebral Osteophyte Accompanied by Lumbosacral Transitional Vertebra: A Case Treated by Anterior Approach

BACKGROUND

Several authors have reported the occurrence of extraforaminal L5 nerve root compression between lumbosacral transitional vertebrae (LSTV) and sacral ala, but reports on a lesion caused by an intervertebral osteophyte on the ventral and contralateral side of a unilateral abnormality by LSTV are hardly available.

CASE DESCRIPTION

A 67-year-old woman presented with pain along the distribution of the L5 nerve root; straight leg raise test, femoral nerve stretch test, and Kemp test were positive on the left. Following plain radiographs, computerized tomography, magnetic resonance imaging, and selective nerve root block, an osteophyte bridging the L5 and S1 vertebral bodies in the ventral side was identified compressing the L5 nerve root. On account of resistance to conservative therapy and the delicate position of the lesion, surgical treatment was performed by an anterior decompression. Subsequently, the patient attained adequate relief from pain and could walk normally.

CONCLUSION

We herein present a very rare case of extraforaminal L5 nerve root compression caused by an intervertebral osteophyte on the ventral and contralateral side of a unilateral abnormality by LSTV, which was managed by anterior decompression.

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.