Laparoscopic discectomy with anterior interbody fusion of L5-S1

Endoscopic Anterior Lumbar Interbody Fusion: Systematic Review and Meta-Analysis

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: "(laparoscopic OR endoscopic) AND (anterior AND lumbar)." Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio's "metafor" package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6-43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9-90.4). Complications occurred in 19.2% (95% CI, 13.4-27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6-11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

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.

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.].

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.

An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach

Extreme/direct lateral interbody fusion (X/DLIF) has been used to treat various lumbar diseases. However, it involves risks to injure the lumbar plexus and abdominal large vessels when it gains access to the lumbar spine via lateral approach that passes through the retroperitoneal fat and psoas major muscle. This study was aimed to determine the distribution of psoas major and abdominal large vessels at lumbar intervertebral spaces in order to select an appropriate X/DLIF approach to avoid nerve and large vessels injury. Magnetic resonance imaging scanning on lumbar intervertebral spaces was performed in 48 patients (24 males, 24 females, 54.2 years on average). According to Moro's method, lumbar intervertebral space was divided into six zones A, I, II, III, IV and P. Thickness of psoas major was measured and distribution of abdominal large vessels was surveyed at each zone. The results show vena cava migrate from the right of zone A to the right of zone I at L1/2-L4/5; abdominal aorta was located mostly to the left of zone A at L1/2-L3/4 and divided into bilateral iliac arteries at L4/5; Psoas major was tenuous and dorsal at L1/2 and L2/3, large and ventral at L3/4 and L4/5. Combined with the distribution of nerve roots reported by Moro, X/DLIF approach is safe via zones II-III at L1/2 and L2/3, and via zone II at L3/4. At L4/5, it is safe via zones I-II in left and via zone II in right side, respectively.

Two-year clinical and radiographic success of minimally invasive lateral transpsoas approach for the treatment of degenerative lumbar conditions

Background

The lateral transpsoas approach to interbody fusion is a less disruptive but direct-visualization approach for anterior/anterolateral fusion of the thoracolumbar spine. Several reports have detailed the technique, the safety of the approach, and the short term clinical benefits. However, no published studies to date have reported the long term clinical and radiographic success of the procedure.

Materials and methods

The current study is a retrospective chart review of prospectively collected clinical and radiographic outcomes in 62 patients having undergone the Anterolateral transpsoas procedure at a single institution for anterior column stabilization as treatment for degenerative conditions, including degenerative disk disease, spondylolisthesis, scoliosis, and stenosis. Only patients who were a minimum of 2 years postoperative were included in this evaluation. Clinical outcomes measured included visual analog pain scales (VAS) and Oswestry disability index (ODI). Radiographic outcomes included identification of successful arthrodesis.

Results

Sixty-two patients were treated with lateral interbody fusion between 2003 and December 2006. Twenty-six patients (42%) were single-level, 13 (21%) 2-level, and 23 (37%) 3- or more levels. Forty-five (73%) included supplemental posterior pedicle fixation, 4 (6%) lateral fixation, and 13 (21%) were stand-alone. Pain scores (VAS) decreased significantly from preoperative to 2 years follow-up by 37% (P < .0001). Functional scores (ODI) decreased significantly by 39% from preoperative to 2 years follow-up (P < .0001). Clinical success by ODI-change definition was achieved in 71% of patients. Radiographic success was achieved in 91% of patients, with 1 patient with pseudarthrosis requiring posterior revision.

Conclusion

The lateral transpsoas approach is similar to a traditional anterior lumbar interbody fusion, in that access is obtained through a retroperitoneal, direct-visualization exposure, and a large implant can be placed in the interspace to achieve disk height and alignment correction. The 2 years plus clinical and radiographic success rates are similar to or better than those reported for traditional anterior and posterior approach procedures, which, coupled with significant short-term benefits of minimal morbidity, make the lateral approach a safe and effective treatment option for anterior/anterolateral lumbar fusions.

Thoracoscopy-assisted mini-open surgery for anterior column reconstruction in thoracic spinal tuberculosis

OBJECTIVE

To evaluate the clinical effects of thoracoscopy-assisted mini-open surgery for anterior column reconstruction in thoracic spinal tuberculosis.

METHODS

Fifty-eight patients, 35 men and 23 women, aged 39.2 (range, 19-60) years with thoracic spinal tuberculosis with an average kyphotic angle of 29.2° (range, 18°-42°) underwent thoracoscopy-assisted mini-open surgeries, including thorough debridement and anterior spinal reconstruction. According to the Frankel Grading system, preoperative neurological function was judged as Grade B in 3 cases, Grade C in 7, Grade D in 28, and Grade E in 20. All patients were followed up for an average of 4.6 years. Outcomes were evaluated retrospectively.

RESULTS

Surgery was accomplished successfully in all cases. The average operation time was 230 min (range, 180-320 min), the average intraoperative blood loss 570 ml (range, 350-1200 ml), and the mean drainage duration 3.6 days (3-5 days). Complications occurred in 19 patients (32.8%). Neurological improvement of one to three grades had occurred in 29 patients by final follow-up. The average correction rate of the kyphotic angle was 36.4%, and no obvious correction loss was detected during follow-up. No recurrent tuberculosis was found in the group.

CONCLUSIONS

Thoracoscopy-assisted mini-open surgery provides a simple, safe, effective, and practical technology with minimal invasiveness for the treatment of thoracic spinal tuberculosis.

Mini-open anterior approach for corpectomy in the thoracolumbar spine

BACKGROUND

Traditional open anterior approaches to the TL spine were reported with a significant morbidity from a large wound field; therefore, "minimally invasive" thoracoscopic and laparoscopic anterior approaches have been recently introduced. However, these endoscopic techniques require a long and steep learning curve, require expensive disposable endoscopy material, and may be little suited for complication management. Alternatively, "mini-open" anterior approaches with table-mounted retractor systems have also been recently introduced.

METHODS

Thirty-seven patients underwent a single-level thoracic or lumbar corpectomy and cage reconstruction for an unstable traumatic burst fracture or vertebral body tumor. A transthoracic (n = 6), transthoracic transdiaphragmatic (n = 23), or retroperitoneal (n = 8) mini-open approach was conducted with the SynFrame (Stratec Medical, Oberdorf, Switzerland) table-mounted retractor. Prior posterior pedicle screw fixation was performed in 35 of 37 patients.

RESULTS

The mean surgical duration of the anterior approach was 181 minutes, and the average blood loss was 632 mL. There was no neurological worsening. On a VAS from 0 to 10, the mean local pain from the anterior approach was 1.7 at 6 months postoperatively, 1.4 at 12 months, and 1.0 at 24 months. Construct stability was found in all patients at 6 months after surgery. Six transient complications occurred.

CONCLUSIONS

The mini-open anterior approach for corpectomy in the TL spine is safe, reliable, and economical. The table-mounted SynFrame retractor provides a stable operating field through which a familiar direct 3-dimensional view of the anterior TL spine is obtained with limited approach morbidity. This technique is an excellent alternative to thoracoscopic or laparoscopic procedures, avoiding the steep learning curve, technical difficulties, and equipment costs of endoscopic procedures.

Variation in reported safety of lumbar interbody fusion: influence of industrial sponsorship and other study characteristics

STUDY DESIGN

Systematic review.

OBJECTIVE

To quantify variability in undesirable outcomes among studies of lumbar interbody fusion using stand-alone cage devices, and to determine whether author conflicts of interest contribute to variability.

SUMMARY OF BACKGROUND DATA

Promising early studies of lumbar fusion with stand-alone cage devices led to rapid uptake of the technique, but some surgeons later expressed reservations regarding efficacy and safety.

METHODS

We systematically identified studies of lumbar interbody fusion with stand-alone cage devices that reported at least one undesirable outcome among 10 or more adult subjects. We performed meta-analyses of rates of 7 prespecified outcomes (nonunion, reoperation, major vessel injury, retrograde ejaculation, neurologic injury, dural injury, and infection). Heterogeneity in outcome rates was quantified as I2 (the proportion of variance due to differences among studies rather than random variation). Random-effects meta-regression identified sources of observed heterogeneity, including potential conflicts of interest.

RESULTS

We identified 30 eligible studies, including a total of 3228 subjects. A potential conflict of interest was identified in 18 (60%). We observed marked heterogeneity in rates of nonunion, reoperation, and neurologic injury (I2 > 85%; P < 0.001), and substantial heterogeneity in rates of dural injury (I2 = 63%; P < 0.01) and major vessel injury (I2 = 38%; P = 0.09). Among 24 studies reporting fusion status after 6 months of follow-up, nonunion rates ranged from 2.3% to 83.3% (median, 8.3%) and exceeded 45% in 4 studies. Potential author conflict of interest was associated with significantly lower rates of nonunion (P = 0.001). Heterogeneity in rates of other undesirable outcomes was not significantly associated with author conflicts of interest or other study characteristics.

CONCLUSION

We quantified substantial unexplained variation in reported complication rates of undesirable outcomes of lumbar interbody fusion with stand-alone cage devices. Authors with potential conflicts of interest, however, reported significantly lower rates of nonunion.

Minimally Invasive Fusion and Fixation Techniques

Instrumented fusion plays an important role in treating a variety of degenerative and traumatic diseases of the spine. Traditional open techniques have been associated with a high degree of approach-related morbidity because of muscle retraction and blood loss. A variety of minimally invasive techniques have been developed for instrumentation of the entire spine. Advances in our understanding of the cellular and molecular mechanisms for stable bony fusion should promote the use of even less invasive techniques in the future.

Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion

BACKGROUND

Minimally disruptive approaches to the anterior lumbar spine continue to evolve in a quest to reduce approach-related morbidity. A lateral retroperitoneal, trans-psoas approach to the anterior disc space allows for complete discectomy, distraction, and interbody fusion without the need for an approach surgeon.

PURPOSE

To demonstrate the feasibility of a minimally disruptive lateral retroperitoneal approach and the advantages to patient recovery.

METHODS/RESULTS

The extreme lateral approach (Extreme Lateral Interbody Fusion [XLIF]) is described in a step-wise manner. There have been no complications thus far in the author's first 13 patients.

CONCLUSIONS

The XLIF approach allows for anterior access to the disc space without an approach surgeon or the complications of an anterior intra-abdominal procedure. Longer-term follow-up and data analysis are under way, but initial findings are encouraging.

Minimally disruptive decompression and transforaminal lumbar interbody fusion

BACKGROUND

Posterior spinal procedures through tubular exposures have been described. However, tubes restrain visibility and require co-axial instrument manipulation, increasing difficulty and potentially compromising surgical results. An independent-blade retractor system overcomes the obstacles of working through a tube and has been used to perform minimally-disruptive decompression and instrumented tranforaminal lumbar interbody fusion (TLIF).

PURPOSE

To evaluate the advantages to patient recovery and surgical efficacy of this technique.

METHODS/RESULTS

Retrospective review of technique employing a minimally-disruptive approach to decompression and transforaminal lumber interbody fusion (TLIF).

CONCLUSIONS

Minimally-disruptive decompression and instrumented TLIF can be performed in a safe and effective manner using an independent-blade retractor system. Relative to traditional-open techniques, surgical goals can be accomplished, but with the benefits of minimally-disruptive surgery.

Minimally-invasive technique for transforaminal lumbar interbody fusion (TLIF)

Minimal access surgical techniques have been described for diskectomy and laminectomy procedures performed through tubular exposures. Tubular exposures, however, restrain visibility to a fixed diameter and require co-axial instrument manipulation. An independent blade retractor system has been developed to overcome the obstacles of working through a tube. Decompression and circumferential fusion can be accomplished through this minimal access exposure via a combination of laminectomy and transforaminal lumbar interbody fusion (TLIF) coupled with minimally invasive pedicle screw fixation. Herein, we describe a minimally-invasive technique for TLIF exposure. Illustrations, intraoperative photographs, and fluoroscopic images supplement this technique. We found that the described minimally-invasive system provides comparable exposure to the traditional-open techniques with the benefits of minimally-invasive techniques. Additionally, it does not have the added constraints of a tubular system. We were able to perform TLIFs without any additional complications. Minimal access decompression and TLIF can be performed safely and effectively using this minimally-invasive system. Besides the retractor system, no additional specialized instruments are required. An operative microscope is not required, in fact, all our cases were performed using operative loupes. The light attachment provides superb visbility without the discomfort of having to wear a headlight. Thus far we have found no added risks or complications using this system. We are currently working on long-term analysis and follow-up to further evaluate this system's efficacy.

Comparative study of laparoscopic L5-S1 fusion versus open mini-ALIF, with a minimum 2-year follow-up

Anterior lumbar interbody fusion (ALIF) is a widely accepted tool for management of painful degenerative disc disease. Recently, the modern laparoscopic surgical technique has been combined with ALIF procedure, with good early postoperative results being reported. However, the benefit of laparoscopic fusion is poorly defined compared with its open counterpart. This study aimed to compare perioperative parameters and minimum 2-year follow-up outcome for laparoscopic and open anterior surgical approach for L5-S1 fusion. The data of 54 consecutive patients who underwent anterior lumbar interbody fusion (ALIF) of L5-S1 from 1997 to 1999 were collected prospectively. More than 2-years' follow-up data were available for 47 of these patients. In all cases, carbon cage and autologous bone graft were used for fusion. Twenty-five patients underwent a laparoscopic procedure and 22 an open mini-ALIF. Three laparoscopic procedures were converted to open ones. For perioperative parameters only, the operative time was statistically different (P=0.001), while length of postoperative hospital stay and blood loss were not. The incidence of operative complications was three in the laparoscopic group and two in the open mini-ALIF group. After a follow-up period of at least 2 years, the two groups showed no statistical difference in pain, measured by visual analog scale, in the Oswestry Disability Index or in the Patient Satisfaction Index. The fusion rate was 91% in both groups. The laparoscopic ALIF for L5-S1 showed similar clinical and radiological outcome when compared with open mini-ALIF, but significant advantages were not identified, despite its technical difficulty.

Is Laparoscopic Anterior Lumbar Interbody Fusion a Useful Minimally Invasive Procedure?

OBJECTIVE

Laparoscopic anterior lumbar interbody fusion (LALIF) has been demonstrated to be safe and effective. Its use as a standard surgical technique has been recommended for arthrodesis in the lumbosacral region. We reviewed our experience with LALIF for safety, effectiveness, and usefulness.

METHODS

Retrospective review of 14 patients who underwent LALIF was performed. All patients had a diagnosis of degenerative disc disease with medically retractable mechanical back pain.

RESULTS

No intraoperative vascular or neurological injury was encountered. An average operating time of 300 minutes with blood loss of 60 ml was found. The average hospital stay was 3.4 days. At 3 to 6 months after surgery, 80% fusion rates were achieved.

CONCLUSION

Although LALIF is a safe and effective procedure, it has many disadvantages, which make it a less than optimal procedure for routine use. Other minimally invasive approaches to the anterior lumbar spine result in similar beneficial results without the drawbacks associated with LALIF.

Low fusion rate after L5-S1 laparoscopic anterior lumbar interbody fusion using twin stand-alone carbon fiber cages

STUDY DESIGN

Prospective study of a cohort of patients who underwent L5-S1 laparoscopic anterior lumbar interbody fusion.

OBJECTIVES

To assess the fusion rate and the clinical outcome more than 2 years after L5-S1 laparoscopic anterior lumbar interbody fusion using twin stand-alone carbon-fiber cages.

SUMMARY OF BACKGROUND DATA

The first reports on laparoscopic anterior lumbar interbody fusion using stand-alone cages appeared in 1995. Since then several articles have reported contradictory data regarding fusion rate. There are no publications describing the fusion rate of stand-alone lumbar carbon-fiber cages.

METHODS

The authors evaluated 12 patients (mean age 36.5 years) in whom endoscopic L5-S1 anterior lumbar interbody fusion was performed using twin stand-alone laparoscopic carbon-fiber cages. Clinical evaluation was carried out prospectively by the use of three self-evaluation scales. Radiologic evaluation was performed by an independent radiologist using dynamic flexion-extension films and CT scans at 6 and 12 months after surgery and subsequently every year until fusion was demonstrated.

RESULTS

After a mean follow-up of 36.6 months (range 24-63 months) the clinical condition of the patients was significantly better than their preoperative status: visual analog scale (P < 0.01), Prolo score (P < 0.05), and Waddell Disability Index (P < 0.01). L5-S1 mobility did not exceed 5 degrees in any dynamic study. However, the overall CT scan fusion rate at 2 years of follow-up was 16.6%. Three years after surgery, CT demonstrated fusion in one of five patients.

CONCLUSION

Two years after endoscopic L5-S1 anterior lumbar interbody fusion using twin stand-alone laparoscopic carbon-fiber cages, the fusion rate was unacceptably low. However, the clinical outcomes of these patients were significantly improved compared with their preoperative status.

Comparison of the mini-open versus laparoscopic approach for anterior lumbar interbody fusion: a retrospective review

OBJECTIVE

The anterior lumbar interbody fusion (ALIF) procedure has become an accepted fusion technique for treating patients with degenerative disorders of the lumbar spine. Many consider laparoscopic ALIF to be the least invasive approach. A modification of the open laparotomy--the "mini-open" approach--is an attractive alternative. In this retrospective review, a comparison of these two ALIF approaches is presented.

METHODS

We conducted a retrospective review of 98 patients who underwent ALIF procedures between 1996 and 2001 in which either a mini-open or a laparoscopic approach was used. Patient demographics, intraoperative parameters, length of hospitalization, and technique-related complications associated with the use of these two approaches were compared. The subset of patients who underwent L5-S1 ALIF procedures was analyzed separately. Statistical analysis was conducted with chi2 and Student's paired t tests.

RESULTS

Between 1996 and 2001, a total of 98 patients underwent ALIF. A laparoscopic approach was used in 47 of these patients, and the mini-open technique was used in the other 51 patients. Operative preparation and procedure time were longer with the use of a laparoscopic approach, and significantly greater during L5-S1 ALIF procedures (P < 0.05). A marginal but significant increase in length of stay was observed after mini-open ALIF procedures (P < 0.05). The immediate postoperative complication rate was greater after mini-open ALIF procedures, 17.6 versus 4.3% (P < 0.05); however, the rate of retrograde ejaculation was higher in the laparoscopic group, 45 versus 6% (P < 0.05).

CONCLUSION

Both the laparoscopic and mini-open techniques are effective approaches to use when performing ALIF procedures. On the basis of the data obtained in this retrospective review, the laparoscopic approach does not seem to have a definitive advantage over the mini-open exposure, particularly in an L5-S1 ALIF procedure. In our opinion, the mini-open approach possesses a number of theoretical advantages; however, the individual surgeon's preference ultimately is likely to be the dictating factor.

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

STUDY DESIGN

A prospective comparison of 50 consecutive patients who underwent L4-L5 anterior lumbar interbody fusion (ALIF).

OBJECTIVES

To compare surgical time, blood loss, time in hospital, complications and adequacy of exposure between laparoscopic and mini-ALIF surgical approaches for L4-L5 anterior spinal fusion.

SUMMARY OF BACKGROUND DATA

Advances in minimally invasive laparoscopic techniques have resulted in many centers adopting the endoscopic approach to L5-S1 as routine. However, the endoscopic approach to L4-L5 can be much more difficult. A direct comparison of open and laparoscopic techniques of exposure has not been reported.

METHODS

From 1995 through 1998, data were prospectively collected on a series of 50 consecutive patients who underwent L4-L5 anterior interbody fusion with a threaded device, by either a laparoscopic or an open mini-ALIF approach.

RESULTS

Twenty-five patients underwent a laparoscopic procedure and 25 an open mini-ALIF approach. For single-level L4-L5 fusions, there was no statistical difference in operating time, blood loss, or length of hospital stay between laparoscopic or mini-ALIF groups. For two-level procedures, only the operative time differed, with laparoscopic procedures taking 25 minutes longer (P = 0.035). The rate of complications was significantly higher in the laparoscopic group (20% vs. 4%). In the laparoscopic group, 16% of patients had inadequate exposure, with the result that only a single cage was placed. In the open mini-ALIF group, two cages were placed in all cases.

CONCLUSIONS

There does not appear to be a significant advantage at the L4-L5 level of the transperitoneal laparoscopic surgical approach when compared with an open mini-ALIF retroperitoneal technique.

Laparoscopic lumbar interbody spinal fusion

Laparoscopic ALIF is an evolving technique requiring the participation of a laparoscopic surgeon experienced in advanced laparoscopic techniques and knowledgeable in anterior lumbar spinal exposures. Initial enthusiasm for this technique was fostered by the development of interbody fusion devices and a method of exposing the anterior lumbar spine, which takes advantage of the ability of minimally invasive surgeries to improve exposure and visualization while minimizing collateral tissue damage and injury to healthy tissue. Preliminary studies have demonstrated laparoscopic ALIF feasibility. These same studies have been able to prove only minor advantages with the laparoscopic versus open technique using the current implants and bone grafting techniques for single-level disc disease. General acceptance of laparoscopic ALIF awaits further investigation. Reasons for a lack of general acceptance include the expense of the interbody fusion devices and laparoscopic equipment, the unfamiliarity of this advanced laparoscopic technique to spine and general surgeons, and the steep learning curve of the procedure. Intraoperative complications that arise are often severe, such as vascular injuries. Many skeptics appropriately believe that initial enthusiasm and zealousness must be tempered with scientific effort that provides data from long-term follow-up. For laparoscopic ALIF to gain general acceptance, randomized comparisons of laparoscopic ALIF to open ALIF and posterior lumbar spinal fusion and controlled studies with long-term follow-up documenting symptomatic outcome variables and spinal fusion rates must be completed. As new modalities are developed, minimally invasive techniques may facilitate their utility. The indications, procedures, and surgical principles of ALIF are unchanged, and physicians must not invent indications to justify the technique; however, eventually we may be able to redefine the indications to take full advantage of the endoscopic techniques and biological advances.

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND

Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease.

METHODS

Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations.

RESULTS

Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group.

CONCLUSIONS

Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.

An Open, Minimally Invasive Approach to the Lumbar Spine

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6–10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11–52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5–12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60–330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.