Access related complications in anterior lumbar surgery performed by spinal surgeons

Elevated Body Mass Index in Patients Undergoing Stand-alone Anterior and Lateral Lumbar Interbody Fusion: Complications, Hospital Length of Stay, and Cost

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aims to evaluate the impact of body mass index (BMI) on postoperative outcomes following anterior, extreme lateral, and oblique lumbar interbody fusion (A/X/OLIF).

BACKGROUND

Obesity is an increasingly common comorbidity among spine surgery patients, potentially leading to elevated postoperative complications. Little is known about the safety of A/X/OLIF approaches in overweight and obese patients.

MATERIALS AND METHODS

The PearlDiver database was queried to identify all adults who underwent single-level A/X/OLIF. Patients were stratified by BMI, defined as healthy weight (≤24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (≥40 kg/m2). Patient demographics and comorbidities were compared before matching, and complications were compared after matching for age, sex, and Charlson Comorbidity Index (CCI).

RESULTS

Among the 36,716 A/X/OLIF included patients, 5464 (14.88%) were healthy weight, 9124 (24.85%) were overweight, 16,283 (44.35%) were obese, and 5845 (15.92%) were morbidly obese. The mean age was 54.4 years, 62.6% were females, and the mean CCI was 1.8. After matching, the mean age was 54.0 years, 70.1% were females, and the mean CCI was 1.4. At 90 days postoperatively, medical and surgical complication rates and readmission generally increased with increasing BMI (all P < 0.010). Length of stay (5.37, 5.51, 5.89, 6.69, P < 0.001) and 90-day costs ($19,326, $19,058, $19,680, $21,103, P = 0.002) also generally increased with increasing BMI. Intraoperative and 2-year complication rates were comparable across cohorts.

CONCLUSIONS

Elevated BMI was associated with increased 90-day postoperative complications but not increased intraoperative or 2-year complications following A/X/OLIF. Optimization for patients with higher BMI should be performed to improve perioperative outcomes, especially in the 90-day postoperative period, and ultimately the safety of these procedures for obese patients.

LEVEL OF EVIDENCE

Level III.

An Update in Complication Rates Associated With Anterior Lumbar Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and meta-analysis.

OBJECTIVE

To conduct an updated systematic review and meta-analysis of complications associated with different anterior fusion techniques/approaches and adjuvant resources (i.e., computed tomography angiography (CTA), rhBMP-2, and access surgeons).

METHODS

A systematic review was conducted from 1/1/2014-4/1/2024 for studies evaluating the incidence of complications associated with anterior lumbar procedures. Comparisons of complications were made between surgical approach, use of CTA, rhBMP-2, and access surgeons. Meta-analyses were conducted using a generalized linear mixed model.

RESULTS

54 studies were included in the final analysis with 8066 patients and an average follow-up of 31.2 months. The overall complication rate associated with anterior lumbar surgery was 13.1%, including an intraoperative complication rate of 3.8%, postoperative complication rate of 7.4%, infection rate of 1.5%, and reoperation rate of 1.7%. Forest plot analysis showed no significant difference in overall complication rates between open and mini-open techniques, although mini-open techniques were associated with lower overall reoperation rates. The use of CTA was associated with an increase in intraoperative and overall complications, and the use of an access surgeon was associated with a decreased risk of reoperation. The use of rhBMP-2 was not associated with overall complication risk.

CONCLUSIONS

While anterior lumbar surgery provides numerous benefits, surgeons and patients alike should be aware of the complication and safety profile prior to surgery. High quality studies are warranted to help elucidate the true benefit of certain techniques and adjuvant resources in reducing complications.

Early Diet Liberalization After Anterior Lumbar Interbody Fusion Improves Postoperative Recovery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

The objective of this study was to assess the impact of diet liberalization on short-term outcomes in patients undergoing anterior interbody lumbar fusion (ALIF).

METHODS

A retrospective review was performed for patients undergoing ALIF at our tertiary care center institution from 2010 to 2022. Electronic medical records were reviewed for demographics, surgical characteristics, and 90-day postoperative outcomes.

RESULTS

We included 515 patients in this study with 102 patients receiving a full diet on the same day as their operation. All other patients had a delay of at least 1 day (average 1.6 days) until a full diet was provided. This group was found to have a higher rate of postoperative ileus (10.2% vs 2.9%) and urinary retention (16.0% vs 3.9%). The readmission rate and percent of patients presenting to the emergency department within 90 days postoperatively were similar. On multivariate regression analysis, same-day, full-diet patients had decreased odds of developing urinary retention (OR = .17) and a shorter length of hospital stay (Estimate: -.99). Immediate full diet had no impact on the development of ileus (OR: .33).

CONCLUSIONS

An immediate postoperative full diet following an anterior approach to the lumbar spine was not found to be associated with an increased risk of postoperative ileus in patients deemed appropriate for early diet liberalization. Moreover, an early full diet was found to reduce length of hospitalization and risk of postoperative urinary retention. Reconsideration of postoperative diet protocols may help optimize patient outcomes and recovery.

Step by step teaching anatomy for anterior approach of the lumbar spine: A cadaveric study

PURPOSE

The authors described detailed relevant anatomy for anterior approach of the lumbosacral spine emphasizing all critical structures at risk for surgical injuries.

METHODS

Two fresh adult male cadavers were dissected at the Toulouse anatomy department. For each specimen, a step-by-step surgical approach followed by broader anatomical dissection was performed.

RESULTS

Results were divided into three compartments: anterior abdominal wall, latero/retroperitoneal space, lumbosacral prevertebral space. Each compartment was analyzed and visually described according to surgical and wider anatomical approach. Each region has critical anatomical structures that need to be well managed during surgery avoiding surgical complications. In the lumbosacral prevertebral space, the vascular anatomy is the most critical point to know to avoid potentially fatal surgical complications for patients. Ureter embedded into the posterior part of the peritoneum is also a critical structure to manage correctly during lumbosacral anterior approach. Different neural structures are also encountered with potential painful complications in case of injury.

CONCLUSIONS

In reference to anterior lumbosacral approach, critical structures to manage are peritoneum, ureter, prevertebral venous structures and hypogastric plexus. Their surgical anatomy has to be known and well recognized during surgery. Our surgical then broader anatomical dissections provide pragmatic pictural pedagogic content for teaching surgeons practicing anterior lumbosacral approach.

Does Perioperative Subcutaneous Heparin or Intravenous Tranexamic Acid Affect the Rate of Vascular Complications in Anterior Lumbar Interbody Fusion Procedures?

Introduction Anterior lumbar interbody fusion (ALIF) is a surgical technique commonly used to treat degenerative disk disease in the lower lumbar spine. As the procedure commonly involves retraction of the iliac arteries and veins, potential complications include deep vein thrombosis (DVT) and hemorrhagic vessel injuries. The goal of this retrospective review is to assess whether the use of intraoperative intravenous tranexamic acid (TXA), subcutaneous heparin (SCH), or neither is associated with clinical complications and surgical outcomes. Methods All patients undergoing ALIF from 2015 to 2023 at a tertiary academic medical center were reviewed. Intraoperative use of prothrombotic or anticoagulant and short- and long-term outcomes were assessed. Results One hundred seventy-nine patients were included; there were 81 (45.3%) female patients and an average age of 58.96 ± 13.34 years. Twenty-eight patients received SCH, 34 patients received TXA, and 117 received neither. The use of perioperative SCH or TXA in ALIF procedures did not result in statistically significant differences in complication rates or pain scores. Statistically significant differences were found with the use of coagulative intervention and blood transfusions, with the TXA requiring the fewest transfusions and the no-intervention group requiring the most. Patients receiving TXA were more likely to be discharged home without the need for any other services. Although not statistically significant, there was a trend of decreasing estimated blood loss (EBL) between the coagulation intervention groups, with no intervention having the highest EBL, followed by SCH and TXA. Conclusion The use of perioperative coagulative intervention in ALIF procedures did not result in a significant change in complication rates, hospital stays, or pain outcomes. The TXA group had a trend toward lower blood loss, no patients requiring a blood transfusion, a higher likelihood of being discharged home without any supplemental services, and the best neurologic outcomes. As such, further large and prospective trials should be performed to study the effect of TXA in ALIF patients further to determine whether patients undergoing ALIFs would benefit from TXA administration.

Anterior Lumbar Interbody Fusion Versus Oblique Lumbar Interbody Fusion Versus Lateral Lumbar Interbody Fusion: Which One in Which Patient?

Anterolateral approaches to the lumbar spine provide direct access to the disc space. These techniques facilitate thorough discectomy, which is essential for successful arthrodesis. They improve segmental lordosis without osteotomy and indirectly decompress neural elements in carefully selected patients. Benefits include shorter operative times, reduced blood loss, and rapid postoperative mobilization compared to posterior approaches. Each technique has specific advantages and limitations, thus none is inherently superior to another. Detailed knowledge of these techniques is essential for modern spine surgeon to provide personalized operative plan for each patient.

Anterior lumbar interbody fusion: patient selection and workup

Anterior lumbar interbody fusion (ALIF) is an anterior surgical approach for interbody fusion in the lumbar spine which affords the surgeon unfettered access to the disc space and allows for release of the anterior longitudinal ligament and insertion of a large, lordotic interbody graft. Despite the benefits associated with ALIF when compared with other lumbar interbody fusion techniques, the ALIF approach is associated with a number of unique complications, and certain patient-specific criteria (e.g., vascular anatomy) are important considerations when selecting patients for an ALIF. This review article summarizes the authors' own patient selection criteria for ALIF and describes the items required for pre-operative workup. Notable criteria to consider when planning an ALIF include: patient age, sex, bone density, body mass index, nicotine usage history, the presence-and severity of-medical comorbidities, anatomy of the distal iliac vein/abdominal aorta/iliac bifurcation/iliocaval confluence, history of prior abdominal surgery/infection/radiotherapy, surgical goals, operative level and availability of approach co-surgeons. Pre-operative workup for ALIF procedures should at a minimum consist of magnetic resonance imaging of the lumbar spine, standing X-rays of the lumbar spine with flexion/extension views, scoliosis or long-cassette spinal X-rays and a computed tomography of the lumbar spine without contrast as well as a dual-energy X-ray absorptiometry scan.

Impact of Age on the Occurrence of Vascular Complications in Patients Undergoing Anterior Lumbar Approach Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery.

BACKGROUND

Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature.

PATIENTS AND METHODS

In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications.

RESULTS

Overall mean age was 50.4 years (range: 20-83 yr). The mean estimated blood loss was 91.3 mL (range: 10-2800 mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721 mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group ( P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications ( P > 0.17).

CONCLUSION

Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery.

LEVEL OF EVIDENCE

Level III.

Lateral decubitus anterior exposure of the L4-5 disc maintains safety compared with supine positioning

Background

Anterior retroperitoneal lumbar spinal exposure has traditionally been performed in the supine position (SUP) to access the L4-L5 and L5-S1 disc spaces where lateral approaches may be unsafe. However, advancements in lateral single position surgery have resulted in advocacy for anterior L4-5 disc access in the lateral decubitus position (LAT). While L5-S1 access in the lateral position is well-described, no series of L4-5 anterior access in the lateral position has been published. The study aims to evaluate the safety of anterior lumbar exposure at the L4-5 disc level in the LAT compared to the SUP.

Methods

A multi-center retrospective study of patients who underwent anterior retroperitoneal lumbar exposure involving the L4-5 disc level were classified according to patient positioning: (I) LAT or (II) SUP.

Results

One hundred and forty patients were included, of which 65 LAT and 75 SUP patients. Two hundred and thirty-eight anterior levels were exposed, including 113 levels performed in lateral and 125 levels in supine. Mean anterior levels fused was similar (1.74 vs. 1.67 levels, P=0.37). Significantly more LAT patients underwent additional lateral lumbar interbody fusion (LLIF) (21.50% vs. 0.00%, P<0.001). A larger proportion of LAT patients underwent surgery for spinal deformity (21.50% vs. 6.70%, P=0.01) and planned staged procedures (21.50% vs. 6.70%, P=0.01). Intraoperative complication rates were similar (3.10% vs. 4.00%, P=0.77), including similar vascular injury rates (1.50% vs. 0.00%, P=0.28) and no visceral injury. Postoperative complications (15.40% vs. 38.70%, P=0.002) were significantly lower in the LAT group, however major complications (6.20% vs. 13.30%, P=0.16) were similar between groups. Fewer LAT patients experienced postoperative ileus (0.00% vs. 6.70%, P=0.03). The rate of reoperation within 30 days (3.10% vs. 6.70%, P=0.33) and 90 days (3.10% vs. 10.70%, P=0.09) were similar between groups.

Conclusions

Anterior lumbar spinal exposure of the L4-5 disc in the LAT is safe compared to supine exposure, despite higher case complexity in the lateral position.

Analysis of the Frequency of Intraoperative Complications in Anterior Lumbar Interbody Fusion: A Systematic Review

OBJECTIVE

We assessed the frequency of intraoperative complication rates related to access surgery, operating time, and intraoperative bleeding rates described in the literature for patients undergoing anterior lumbar interbody fusion (ALIF) to evaluate the adverse effects and, thus, help in therapeutic decision making and contribute to future clinical trials.

METHODS

A systematic review was conducted of MEDLINE and Embase databases in March 2023. The main inclusion criteria were adult patients aged >18 years, with no maximum age limit; the use of ALIF; the presence of quantitative data on intraoperative complications; and randomized controlled trials and cohort studies. Vascular and peritoneal injuries were considered primary endpoints. The operative time and intraoperative bleeding rate were secondary endpoints. Reports and case series, case-control series, systematic reviews, and meta-analyses were excluded.

RESULTS

Eight studies were included with a total of 2395 patients. We found important quantitative data for future randomized clinical studies involving ALIF surgery, including the rate of vascular lesions (2.79%) and peritoneal lesions (0.37%). In addition to these factors, only 4 of the 8 studies addressed the average surgery time, with a total average of 145.61 minutes. Furthermore, 6 of the 8 articles reported the mean rate of intraoperative bleeding, with a total mean blood loss of 272.75 mL.

CONCLUSIONS

ALIF is a lumbar spine access technique with low intraoperative complications. Patients with contraindications have a higher risk of complications. Randomized clinical trials are needed to assess the efficacy and safety of the procedure.

Clinical and Radiographic Outcomes of Anterior Lumbar Interbody Fusion With Anterior Plate Fixation

BACKGROUND

Reports on the outcomes following instrumented anterior lumbar interbody fusion (ALIF) with anterior plate fixation are limited. The aim of this study was to assess the clinical and radiographic outcomes of patients undergoing ALIF with anterior plate fixation.  Methods: Medical records and radiographic imaging were reviewed for 100 patients who received ALIF with anterior plate fixation between 2008 to 2021 and completed at least one year of follow-up and postoperative imaging. Prospectively collected patient data included indication for surgery, BMI, age, number and location of levels treated, complications, reoperation rates, fusion rate, and measurements of global lordosis, disc space height, and segmental angulation.  Results: A total of 100 patients were included in this study. The mean length of follow-up was 81.37 months. Changes in preoperative-to-postoperative Oswestry Disability Index (ODI) and Visual Analog Score (VAS) demonstrated improvements of 30.86% and 18.56%, respectively. Major vascular injuries occurred in 3% of the cases. A hardware failure rate of 5% was observed. The reoperation rate was 10%. The radiographic fusion rate derived from computed tomography (CT) and plain film was 95.45% and 88.87%, respectively. Postoperative global lordosis demonstrated a 6.08% increase. Postoperative segmental angulation measurements increased by 57.74%. No statistically significant differences in clinical or radiographic outcomes were observed based on the spine level of fusion or the number of fusions performed.  Conclusions: ALIF with anterior plate fixation achieved an adequate fusion rate with improvements in ODI and VAS scores meeting minimal clinically important difference thresholds. Postoperative disc space heights demonstrated significant improvements compared to preoperative measurements.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Lateral approach to the lumbar spine: The utility of an access surgeon

Background

Lateral lumbar interbody fusions (LLIFs) utilize a retroperitoneal approach that avoids the intraperitoneal organs and manipulation of the anterior vasculature encountered in anterior approaches to the lumbar spine. The approach was championed by spinal surgeons; however, general/vasculature surgeons may be more comfortable with the approach.

Objective

The objective of this study was to compare short-term outcomes following LLIF procedures based on whether a spine surgeon or access surgeon performed the approach.

Materials and Methods

We retrospectively identified all one- to two-level LLIFs at a tertiary care center from 2011 to 2021 for degenerative spine disease. Patients were divided into groups based on whether a spine surgeon or general surgeon performed the surgical approach. The electronic medical record was reviewed for hospital readmissions and complication rates.

Results

We identified 239 patients; of which 177 had approaches performed by spine surgeons and 62 by general surgeons. The spine surgeon group had fewer levels with posterior instrumentation (1.40 vs. 2.00; P < 0.001) and decompressed (0.94 vs. 1.25, P = 0.046); however, the two groups had a similar amount of two-level LLIFs (29.9% vs. 27.4%, P = 0.831). This spine surgeon approach group was found to have shorter surgeries (281 vs. 328 min, P = 0.002) and shorter hospital stays Length of Stay (LOS) (3.1 vs. 3.6 days, P = 0.019); however, these differences were largely attributed to the shorter posterior fusion construct. On regression analysis, there was no statistical difference in postoperative complication rates whether or not an access surgeon was utilized (P = 0.226).

Conclusion

Similar outcomes may be seen regardless of whether a spine or access surgeon performs the approach for an LLIF.

Exploration of the Extraperitoneal Approach for Single-Level Anterior Lumbar Interbody Fusion: Imaging, Anatomical and Clinical Research

Background

To explore extraperitoneal approach as an optimal option for reducing peritoneal disruption at a single-level disc in anterior lumbar interbody fusion (ALIF).

Methods

First, abdominal axial CT images obtained from 111 patients were observed to evaluate the distribution of extraperitoneal fat at L2-S1 and measure the lateral distances between the midline and the lateral borders of the rectus and the extraperitoneal fat for each disc level. Second, eight embalmed corpses were dissected along the lateral border of the rectus to expose the peritoneum, which was then separated laterally and medially to evaluate the distribution of fat and peritoneum adhesion. Finally, a total of 58 patients were selected for ALIF. For L2-L4 discs and L4-S1, the pararectus approach and the paramedian approach were utilized, respectively.

Results

Extraperitoneal fat was observed behind the rectus at the L5-S1 and the lateral distance between the fat and midline and the lateral border of the rectus gradually decreased on both sides of L2-5. On the cranial side of the arcuate line, it was easier to separate the peritoneum outward along the lateral edge of the rectus. When bluntly dissected medially, the peritoneum was closely adhered to abdominal wall. No complications such as peritoneal damage, retroperitoneal hematoma and neurological complications occurred in 58 patients undergoing the aforementioned surgical methods.

Conclusions

For L4-S1, the paramedian approach is the optimal technique to expose the disc, whereas the pararectus approach is the feasible surgical method at L2-4.

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

Introduction

Tomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery.

Methods

First-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4–S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4–S1 promontory.

Results

Patient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op.

Conclusion

These are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

Correlation of mental health with physical function, pain, and disability following anterior lumbar interbody fusion

BACKGROUND

Studies have demonstrated the influence of preoperative mental health on outcomes following spine surgery, but prior literature has not assessed the influence of mental health at time of outcome survey collection.

METHODS

Patients who underwent elective anterior lumbar interbody fusion (ALIF) were identified from a prospective registry. Patient-reported outcomes (PROs) were collected preoperatively and up to 1 year postoperatively. Mental health measures studied included 12-item Short Form (SF-12) Mental Component Score (MCS) and Patient Health Questionnaire-9 (PHQ-9). Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), SF-12 Physical Component Score (PCS), visual analog scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) were compared to the mental health measures by Pearson's correlation tests.

RESULTS

A total of 166 patients were included. SF-12 MCS demonstrated positive correlation to PROMIS-PF preoperatively (|r|= 0.379) and at 6 weeks (|r|= 0.387) (p ≤ 0.016, all). SF-12 MCS demonstrated negative correlation to VAS back at 6 months (|r|= 0.359), VAS leg at 6 weeks (|r|= 0.475) and 12 weeks (|r|= 0.422), and ODI up to 6 months postoperatively (|r|= 0.417-0.526) (p ≤ 0.037, all). PHQ-9 negatively correlated with PROMIS-PF at all periods studied (|r|= 0.425-0.587) and SF-12 PCS up to 6 months postoperatively (|r|= 0.367-0.642) (p ≤ 0.016, all). PHQ-9 positively correlated to VAS back at 6 weeks (|r|= 0.408) and 6 months (|r|= 0.411), VAS leg at 6 weeks (|r|= 0.344), and ODI up to 6 months postoperatively (|r|= 0.321-0.669) (p ≤ 0.034, all).

CONCLUSION

Inferior mental health correlated with inferior pain, function, and disability scores at one or more periods postoperatively. This finding was most consistent for correlation between mental health scores and disability. Optimization of mental health may positively influence outcomes, especially regarding disability, following ALIF.

Surgeon Learning Curve and Clinical Outcomes of Minimally Invasive Anterior Lumbar Interbody Fusion With Posterior Percutaneous Instrumentation

OBJECTIVES

This study reports the learning phase of the minimally invasive anterior lumbar interbody fusion (mini-ALIF) approach with a vascular and orthopaedic spine surgeon team.

METHODS

Adult patients who underwent primary mini-ALIF at the lowest two segments of the lumbar spine (i.e., L4/5, L5/S1) between January 2010 and December 2018 were analyzed.

RESULTS

One hundred twenty-seven patients were included. There was no notable change in total surgical time over the study period. Estimated blood loss markedly decreased until stabilizing at case 30 and slowly declined thereafter. The mean estimated blood loss was 184 mL for L5/S1, 232 mL for L4/L5, and 458 mL for two-level mini-ALIF. There were 20 vascular issues requiring primary repair or packing. Vascular issues declined over time, with a rate of 32% in the first 25 cases and 0% in the last 25. The postoperative complication rate was highest in the first 25 cases (7 of 21 total complications). The odds ratio of vascular injury with body mass index (BMI) > 35 was 4.09 (1.4 to 11.7 confidence interval, P ≤ 0.008). Total surgical time and postoperative complications increased with increasing BMI.

CONCLUSION

Performance of the mini-ALIF approach is associated with a learning curve of 25 to 30 cases before complications begin to decline. BMI > 35 is associated with increased surgical time and complications.

Surgical sequence in anterior column realignment with posterior osteotomy is important for degree of adult spinal deformity correction: advantages and indications for posterior to anterior sequence

BACKGROUND

We hypothesized that posterior osteotomy prior to ACR (Anterior column realignment) through P-A-P surgical sequence would permit a greater correction for deformity corrective surgery than the traditional A-P sequence without posterior osteotomy. This study aimed to determine the impact of the P-A-P sequence on the restoration of lumbar lordosis (LL) compared to the A-P sequence in deformity corrective surgery for adult spinal deformity (ASD) patients and to identify the characteristics of patients who require this sequence.  METHODS: Between 2017 and 2019, 260 ASD patients who had undergone combined corrective surgery were reviewed retrospectively. This study included 178 patients who underwent posterior osteotomy before the ACR (P-A group) and 82 patients who underwent the A-P sequence (A-P group). Sagittal spinopelvic parameters were determined from pre- and postoperative whole-spine radiographs and compared between the groups. To find better indications for the P-A-P sequence, we conducted additional analysis on postoperative outcomes of patients in the A-P group.  RESULTS: The P-A group showed a significantly higher change in LL (53.7° vs. 44.3°, p < 0.001), C7 sagittal vertical axis (C7 SVA: 197.4 mm vs. 146.1 mm, p = 0.021), segmental lordosis (SL) L2/3 (16.2° vs. 14.4°, p = 0.043), SL L3/4 (16.2° vs. 13.8°, p = 0.004), and SL L4/5 (15.1° vs. 11.3°, p = 0.001) compared to the A-P group. At the final follow-up, pelvic incidence (PI) minus LL mismatch (PI - LL mismatch) was significantly higher in the A-P group (13.4° vs. 2.9°, p < 0.001). Stepwise logistic regression analysis showed that age ≥ 75 years (odds ratio [OR] = 2.151; 95% confidence interval [CI], 1.414-3.272; p < 0.001), severe osteoporosis (OR = 2.824; 95% CI, 1.481-5.381; p = 0.002), rigid lumbar curve with dynamic changes in LL < 10° (OR = 5.150; 95% CI, 2.296-11.548; p < 0.001), and severe facet joint osteoarthritis (OR = 4.513; 95% CI, 1.958-10.402; p < 0.001) were independent risk factors for PI - LL mismatch ≥ 10° after A-P surgery.

CONCLUSION

P-A-P sequence for deformity corrective surgery in ASD offers greater LL correction than the A-P sequence. Indications for the procedure include patients aged ≥ 75 years, severe osteoporosis, rigid lumbar curve with dynamic change in LL < 10°, or more than four facet joints of Pathria grade 3 in the lumbar region.

Effectiveness of supplemental screw fixation for the prevention of anterior cage migration in oblique lateral interbody fusion at L5-S1

BACKGROUND

The anterior cage at L5-S1 segment is more vulnerable to anterior migration because of the sacral slope, the greater disc angle (DA), the higher shear force, and the weaker pedicle screw fixation at S1. We hypothesized that a supplemental screw (SS) fixation is effective for the prevention of anterior cage migration in oblique lateral interbody fusion (OLIF) at L5-S1.

METHODS

This study involved 61 consecutive patients who underwent OLIF at L5-S1 and had more than 1-year regular follow-up. In the first 35 cases, the anterior cage was fixed with pedicle screws only (non-SS group). In the remaining 26 cases, the anterior cage was fixed with a SS and pedicle screws (SS group). Radiological parameters including anterior disc height (ADH), posterior disc height (PDH), DA, cage migration, cage subsidence, and fusion rate at L5-S1 were compared between the two groups.

RESULT

Of the total 61 patients, fifteen (24.6%) patients had an anterior cage migration of >2 mm and six (9.8%) patients had an anterior cage migration of >5 mm. Baseline demographic characteristics were similar between the two groups. The mean cage migration was 2.0 ± 3.1 mm in the non-SS group and 0.9 ± 0.9 mm in the SS group (P = 0.038). Thirteen (37.1%) patients had a cage migration of >2 mm in the non-SS group, while only two (7.7%) had a cage migration of >2 mm in the SS group (P = 0.002). There were no significant differences in the ADH, PDH, DA, cage subsidence, and fusion rate between the two groups (all P > 0.05). There was no SS-related complication in the SS group.

CONCLUSIONS

SS fixation in front of the anterior L5-S1 cage is simple, safe, and effective for the prevention of anterior cage migration in OLIF at L5-S1.

Need of vascular surgeon and comparison of value for anterior lumbar interbody fusion (ALIF) in lateral decubitus: Delphi consensus

BACKGROUND AND PURPOSE

Anterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years. The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF).

METHODS

A two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF).

RESULTS

A total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements.

CONCLUSIONS

The Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients

BACKGROUND

One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review.

METHODS

This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration.

RESULTS

The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation.

CONCLUSIONS

Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Trends in Surgical Approach for Single-Level Lumbar Fusion Over the Past Decade

STUDY DESIGN

Retrospective Comparative Study.

OBJECTIVE

The purpose of this study was to characterize trends in surgical approach for single-level lumbar fusion over the past decade.

SUMMARY OF BACKGROUND DATA

The number of elective lumbar fusion cases performed is increasing annually. Several different surgical approaches exist for lumbar spinal fusion including novel anterior approaches developed in recent years. With ongoing innovation, trends in the utilization of common surgical approaches in recent years are unclear.

MATERIALS AND METHODS

A retrospective cohort study was conducted using the PearlDiver database (Fort Wayne, IN). Patients undergoing single-level lumbar fusion between 2010 and 2019 were identified using Current Procedural Technology codes and divided into 4 mutually exclusive cohorts based on surgical approach: (1) anterior-only, (2) anterior approach with posterior instrumentation, (3) posterolateral, and (4) posterior-only interbody. Trend analyses of surgical approach utilization over the last decade were performed with the Cochran-Armitage test to evaluate the 2-tailed null hypothesis that utilization of each surgical approach for single-level lumbar fusion remained constant.

RESULTS

A total of 53,234 patients met inclusion criteria and were stratified into 4 cohorts: anterior-only (n=5104), anterior with posterior instrumentation (n=23,515), posterolateral (n=5525), and posterior-only interbody (n=19,090). Trend analysis revealed the utilization of a posterior-only interbody approach significantly decreased from 36.7% to 29.2% (P<0.001), whereas the utilization of a combined anterior and posterior approach significantly increased from 45.8% to 50.4% (P<0.001). The utilization of an anterior-only approach also significantly increased from 7.9% to 10.5% (P<0.001).

CONCLUSIONS

Utilization of anterior-only and anterior with posterior instrumentation approaches for single-level lumbar fusion have been significantly increasing over the past decade while use of posterior-only interbody approach trended significantly downward. These data may be particularly useful for trainees and spine surgeons as new techniques and technology become available.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF).

SUMMARY OF BACKGROUND DATA

ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity.

METHODS

Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient.

RESULTS

A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades.

CONCLUSION

Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.

Intraoperative Complications of Anterior Lumbar Interbody Fusion: A 5-Year Experience of a Group of Spine Surgeons Performing Their Own Approaches

BACKGROUND

Spine surgery has evolved at an accelerated pace, allowing the development of more efficient surgical techniques while providing a decreasing rate of morbimortality. One example of these approaches is the anterior lumbar interbody fusion (ALIF). The aim of this study was to evaluate the surgical complication rate when performing ALIF without the help of a vascular "access" surgeon.

METHODS

A retrospective descriptive study was conducted at the Hospital Universitario San Ignacio between 2014 and 2018 and included all patients who underwent ALIF during this time. A nonsystematic review was performed assessing approach-related complications in ALIF and the impact of "access" surgeons in surgical outcomes.

RESULTS

A total of 337 patients were included and 508 levels were fused. ALIF was performed as ALIF-360° (27%), ALIF-lateral lumbar interbody fusion (LLIF) (8.9%), and stand-alone ALIF (62%). Most procedures were single-level fusions (51.9%), 45.4% involved 2 levels, and 2.6% were 3-level fusions. The mortality rate was 0%, and only 9 cases of vascular injury were observed and described. Left and common iliac veins were the predominant affected structures. Only a single case required blood transfusion without any other treatment or intensive care unit surveillance.

CONCLUSIONS

Our study is consistent with literature reports about ALIF complications, finding an incidence of 1.7%. Therefore, ALIF is an excellent alternative for spine procedures, especially for the levels L5-S1 that require sagittal balance restoration. The approaches were performed without a vascular "access" surgeon and presented complication rates similar to those described in the literature.

Increased risk of postoperative wound complications among obesity classes II & III after ALIF in 10-year ACS-NSQIP analysis of 10,934 cases

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) procedures for lumbar spine disease have been increasing amid a growing obese patient population with limited studies available focusing exclusively on risk-factors for post-operative ALIF complications.

PURPOSE

The objective of this study was to compare 30-day post-operative complications among different obesity World Health Organization classes according to body mass index (BMI) in comparison to non-obese patients who underwent an ALIF procedure.

STUDY DESIGN/SETTING

Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2009 to 2019.

PATIENT SAMPLE

A total of 10,934 patients undergoing an ALIF.

OUTCOME MEASURES

Primary outcome measures include 30 day cardiac, pulmonary, urinary, infectious, and wound complications. Secondary outcomes included rates of blood transfusion, reintubation, deep vein thrombosis, pulmonary embolism, 30-day return to the operating room (OR), and 30 day mortality.

METHODS

Patients were identified by use of the current procedural terminology codes 22558 and 22585 from 2009 to 2019. Patients were divided into the following groups: non-obese (BMI 18.5-29.9 kg/m²), Obese I (BMI 30-34.9 kg/m²), Obese II (BMI 35-39.9 kg/m²), and Obese III (BMI ≥40 kg/m²). Age, gender, race, American Society of Anesthesiologists status, smoking status, hypertension requiring medication, steroid used, chronic obstructive pulmonary disease, history of a bleeding disorder, and diabetes was identified as risk factors after a univariate analysis conducted for demographic variables and pre-operative comorbidities. A multivariate logistic regression analysis was then performed to adjust for these preoperative risk factors and compare obesity classes I-III to non-obese patients.

RESULTS

Obesity classes II and III had a significant odds ratio (OR) for superficial infection (OR:2.7, 95%CI(1.7-4.5); OR:2.8, 95%CI(1.5-5.2) respectively), organ space infection (OR:3.8, 95%CI(1.6-7.4); OR:3.2, 95%CI(1.1-9.9) respectively), wound disruption (OR:2.8, 95%CI(1.1-7.4); OR:4.6, 95%CI(1.6-13.6) respectively), and total wound complication (OR:2.6, 95%CI(1.8-3.9); OR:3.4, 95%CI(2.2-5.4) respectively) following a multivariate logistic regression analysis.

CONCLUSIONS

Risk for post-operative wound complications following an ALIF were found to be significantly higher for obesity classes II-III in comparison to non-obese patients. These findings can further support the use of additional wound care in the perioperative setting for certain levels of obesity.

The Use of a Transforaminal Lumbar Interbody Fusion (TLIF) Cage Following Inadequate Access to the Disc Space During an Anterior Lumbar Interbody Fusion Procedure

Non-specific lower back pain caused by degenerative lumbar disease, such as disc and facet joint degeneration or spondylolisthesis, significantly impairs quality of life of patients and is associated with higher pain scores and reduced function. Patients that fail to respond to conservative treatment may require surgical intervention, such as lumbar interbody fusion (LIF). Compared to other approaches, an anterior approach to lumbar interbody fusion (ALIF) has advantages regarding efficacy of fusion, visualization of relevant anatomy, and a larger allowable size of the interbody fusion device. An anterior approach’s main biomechanical advantage includes the ability to restore sagittal alignment, achieve indirect decompression, and provide increased anterior column support. Complications of anterior interbody fusion are mostly approach related and include vascular injury or visceral injury. However, the anterior anatomy can make the placement of an interbody device challenging. In the case reported here, an ALIF procedure was complicated by immobile iliac vessels leaving a small window to place the interbody cage. Continuing with the anterior approach was opted, but with the oblique placement of a cage traditionally used in transforaminal lumbar interbody fusion (TLIF) procedures.

Influence of Vascular Anatomy on the Radiologic Outcomes in Oblique Lateral Interbody Fusion at L5-S1

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The objective of this study was to evaluate whether the anatomy of the left common iliac vein (LCIV) affects the radiologic outcomes in oblique lateral interbody fusion (OLIF) at L5-S1.

SUMMARY OF BACKGROUND DATA

Upward mobilization and retraction of the LCIV is an essential technique in OLIF at L5-S1. However, mobilization of the LCIV is sometimes difficult and may affect the surgical outcomes in OLIF at L5-S1.

METHODS

This study involved 52 consecutive patients who underwent OLIF at L5-S1 and had >1-year regular follow-up. The configuration of LCIV on preoperative axial magnetic resonance images of the lumbar spine was categorized into 3 types according to the difficulty of mobilization: type I (no requirement for mobilization), type II (potentially easy mobilization), and type III (potentially difficult mobilization). Radiologic parameters included anterior/posterior disk heights (ADH/PDH), disk angle (DA), cage migration, cage subsidence, cage position, and fusion rate at L5-S1. Intraoperative/perioperative events associated with OLIF at L5-S1 were reviewed. Radiologic outcomes among the LCIV types were compared.

RESULTS

There were 19 men and 33 women with a mean age of 62.8±9.7 years. The mean follow-up duration was 24.8±15.5 months. The LCIV anatomy was type I in 25 (48.1%) patients, type II in 14 (26.9%), and type III in 13 (25.0%). The mean ADH increased from 7.0±4.7 to 16.9±4.1 mm at the last follow-up (P<0.001), and the mean PDH increased from 2.7±1.7 to 4.9±1.6 mm (P<0.001). The mean DA increased from 5.4±5.4 to 16.9±6.5 degrees (P<0.001). There were no significant differences in ADH, PDH, and DA at the last follow-up among the LCIV types. Two (3.8%) major and 2 (3.8%) minor LCIV injuries were identified, all of which had a type III LCIV.

CONCLUSIONS

OLIF at L5-S1 showed favorable radiologic outcomes regardless of the LCIV anatomy. However, type III LCIV patients had a high rate of intraoperative vascular injury.

Outcomes of anterior vs. posterior approach to single-level lumbar spinal fusion with interbody device: An analysis of the nationwide inpatient sample

BACKGROUND

Interbody devices have revolutionized lumbar spinal fusion surgery by improving mechanical stability and maximizing fusion potential. Several approaches for interbody fusion exist with two of the most common being anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF). This study aims to compare patient data, hospital outcomes, and post-operative complications between an anterior vs. posterior approach to lumbar interbody fusion.

METHODS

This retrospective cohort study utilized the Nationwide Inpatient Sample (NIS) and International Classification of Diseases, 10th edition (ICD10) codes to identify patients (18 +) from 2016 to 2018 who underwent lumbar interbody fusion under an anterior or posterior approach. Patients missing identifiers were excluded from this study. Patients were further investigated by demographic data and the presence of comorbidities. Hospital outcome data was investigated by length of stay (LOS), total hospital charges, mortality, and post-operative complications.

RESULTS

373,585 patients were included in this study. 257,975 (69%) underwent fusion via a posterior approach, and 115,610 (31%) via an anterior approach. Patients undergoing posterior approach were found to have a greater number of comorbidities than anterior (3.5 vs. 2, respectively, p = <0.001). The posterior approach was associated with decreased LOS (3.59 vs 4.19 days, p = <0.0001) and decreased total hospital charges ($141,700 vs $211,015, p = <0.0001). A posterior approach was found to have lower rates of post-operative complications. For the anterior approach cohort, tobacco dependence (OR=1.31 [1.20-1.42, p = <0.001], diabetes (OR=2.41 [2.33-2.49, p = <0.001], and osteoporosis (OR=1.42 [1.30-1.54, p = <0.001] were found to be significant independent predictors of post-operative pseudoarthrosis. Obesity (OR=1.28 [1.14-1.42, p = <0.001], tobacco dependence (OR=1.48 [1.40-1.56, p = <0.001], diabetes (OR=2.21 [2.10-2.32, p = <0.001], congestive heart failure (OR=1.20 [1.01-1.39, p = 0.04], and osteoporosis (OR=1.65 [1.55-1.75, p = <0.001], were found to be independent predictors of post-operative pseudoarthrosis in the posterior cohort.

CONCLUSIONS

Patients who underwent the anterior approach suffered from increased hospital charges, length of stay, and increased risk of post-operative complications including mortality, wound dehiscence, hematoma/seroma, and pseudoarthrosis. Comorbid disease plays a significant role in the outcome of successful fusion with variable effect depending on the surgical approach. Increasing due diligence in patient selection should be considered when choosing an approach in pre-operative planning.

Factors affecting disc angle restoration in oblique lateral interbody fusion at L5-S1

BACKGROUND CONTEXT

Optimal restoration of the L5-S1 disc angle (DA) is an important surgical goal in spinal reconstructive surgery. Anterior approach is beneficial for L5-S1 DA reconstruction and fusion. However, factors associated with a greater DA restoration in oblique lateral interbody fusion (OLIF) at L5-S1 have not been studied.

PURPOSE

This study aimed to identify factors that aid in achieving a greater DA in OLIF at L5-S1.

STUDY DESIGN/SETTING

A retrospective analysis.

PATIENT SAMPLE

This study involved 61 consecutive patients who underwent OLIF at L5-S1 for lumbar degenerative disease and were followed for more than 1 year. Patients with incomplete data or posterior column osteotomy at L5-S1 were excluded.

OUTCOME MEASURES

The L5-S1 DA was measured preoperatively, postoperatively, and at the last follow-up on standing lateral lumbar radiographs. The associations between demographics and/or surgical and/or radiological factors and the L5-S1 DA at the last follow-up were analyzed using multiple regression analysis.

METHODS

Demographics and surgical factors were reviewed from the medical records with respect to age, sex, body mass index, bone mineral density, diagnosis, surgery level, cage parameters (cage lordotic angle and height), laminectomy performed and/or not performed, estimated blood loss, operative time, configuration of the left common iliac vein. Radiological factors were measured with respect to sagittal parameters, the L5-S1 disc parameters, and the postoperative cage parameters.

RESULTS

The mean preoperative DA at L5-S1 was 5.4±5.0°, which increased to 18.9±5.6° postoperatively (p<.001) and was maintained as 16.5±5.9° at the last follow-up (p<.001). The preoperative DA, end plate lesions, anterior spur, facet joint osteoarthritis, or cage position at L5-S1 did not affect the DA at the last follow-up (all p>.05). Multiple regression analysis showed four independent variables, including increased age, increased cage lordotic angle, laminectomy performed, and absence of cage subsidence as the factors associated with the greater DA at L5-S1.

CONCLUSIONS

OLIF at L5-S1 showed favorable DA restoration regardless of the preoperative conditions. To achieve a greater DA, surgeons should try to distract the anterior disc space for insertion of a larger lordotic cage. Laminectomy during posterior fixation is recommended for achieving additional DA restoration.

Lumbar degenerative disease treated by percutaneous endoscopic transforaminal lumbar interbody fusion or minimally invasive surgery-transforaminal lumbar interbody fusion: a case-matched comparative study

Purpose

This study aimed to evaluate the clinical efficacy and imaging results of percutaneous endoscopic transforaminal lumbar interbody fusion (PETLIF) through comparing it with minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF).

Materials and methods

We performed a retrospective analysis on patients with lumbar degenerative disease treated by PETLIF or MISTLIF from September 2017 to January 2019, and the patients were divided into two groups: the PETLIF group and the MISTLIF group. The clinical and imaging parameters of the two groups were evaluated.

Results

There was no significant difference between the two groups in complication rate. The operative time in the PETLIF group was significantly less than that in the MISTLIF group. Compared with those before operation, the postoperative VAS-L and VAS-B scores were significantly improved after operation in the both groups. In addition, the postoperative VAS-B score of the PETLIF group was significantly lower than that of the MISTLIF group. At the last follow-up, there was no significant difference between the two groups in the VAS-L score, VAS-B score, ODI score, and bony fusion rate.

Conclusions

Both PETLIF and MISTLIF could achieve satisfactory clinical outcomes in the treatment of lumbar degenerative disease, but our study suggested that PETLIF had less damage, rapid recovery after operation, and short discharge time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02841-4.

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.

Development of machine learning and natural language processing algorithms for preoperative prediction and automated identification of intraoperative vascular injury in anterior lumbar spine surgery

BACKGROUND

Intraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture.

PURPOSE

The purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes.

PATIENT SAMPLE

Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis.

OUTCOME MEASURES

The primary outcome was unintended VI during anterior lumbar spine surgery.

METHODS

Manual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes.

RESULTS

In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI (https://sorg-apps.shinyapps.io/lumbar_vascular_injury/). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64.

CONCLUSION

Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting.

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.

Minimally Invasive L5 Corpectomy with Navigated Expandable Vertebral Cage: A Technical Note

Background: Conventional L5 corpectomy requires a large incision and an extended period of intraoperative fluoroscopy. We describe herein a new L5 corpectomy technique. Methods: A 79-year-old woman was referred to our hospital for leg pain and lower back pain due to an L5 vertebral fracture. Her daily life had been affected by severe lower back pain and sciatica for more than 2 months. We initially performed simple decompression surgery, but this proved effective for only 10 months. Results: For revision surgery, the patient underwent minimally invasive L5 corpectomy with a navigated expandable cage without fluoroscopy. The second surgery took 215 min, and estimated blood loss was 750 mL. The revision surgery proved successful, and the patient could then walk using a cane. In terms of clinical outcomes, the Oswestry Disability Index improved from 66% to 24%, and the visual analog scale score for lower back pain improved from 84 to 31 mm at the 1-year follow-up. Conclusions: Minimally invasive L5 corpectomy with a navigated expandable vertebral cage is effective for reducing cage misplacement and surgical invasiveness. With this new technique, surgeons and operating room staff can avoid the risk of adverse events due to intraoperative radiation exposure.

Identifying Risk Factors for Complications During Exposure for Anterior Lumbar Interbody Fusion

Introduction

An anterior approach to lumbar interbody fusion is a widely utilized method of access to the lumbar spine. Due to the potential for vascular complications with spine exposure, vascular surgeons are frequently included in the care of these patients as part of a team-based approach. Identifying risk factors for such complications is difficult and not well-defined in the literature. In this investigation, we evaluate the potential risk factors for complications during anterior lumbar inter-body fusion (ALIF).

Methods

This is a retrospective review of 106 patients who underwent ALIF at a single institution between May 1, 2007, and April 30, 2017. Patients were identified through operating room case logs and Current Procedural Terminology (CPT) codes correlating with ALIF. Vascular surgeons performed all anterior exposures. Patient demographics and data regarding their surgical care and postoperative course were obtained from a review of operative and progress notes in the electronic medical record. Statistical methods employed included a t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were compared using Fisher’s exact and chi-square tests. A logistic regression model was applied to predict complications by controlling other significant covariates.

Results

Of the 106 patients included in this analysis, 16 patients experienced a defined complication, giving an overall complication rate of 15%. Patients with complications were more likely to be of male gender (n=11, P=0.016), with older average age (54.6, P=0.017), with higher estimated blood loss, with higher use of blood products, and with higher use of cell-saver. A venous injury was the most common complication (n=11, 10.4%); ileus and nerve injury were the next most common (n=3, 2.8%). The 30-day mortality was 0%. Male gender demonstrated an odds ratio of 3.78 (P=0 .034) in a logistic regression model after adjusting for age and blood products.

Conclusions

Overall complication rates were comparable to those in the published literature and male gender was identified as a predictor for risk of complications in those undergoing ALIF. This is the first study to identify male sex as a risk factor for complications following ALIF. The results of this study will hopefully guide future studies in gaining more insight into the predictors of complications in larger series.

Comparison of surgical outcomes between oblique lateral interbody fusion (OLIF) and anterior lumbar interbody fusion (ALIF)

OBJECTIVE

Although oblique lateral interbody fusion (OLIF) utilizes the similar approach in anterior lumbar interbody fusion (ALIF), OLIF is essentially a lateral lumbar interbody fusion (LLIF). Therefore, OLIF may have advantages in LLIF that the lateral cage can achieve greater restoration of the disc height and angle. We aimed to compared the surgical outcomes between OLIF and ALIF.

METHODS

This study involved 47 consecutive patients who underwent a single-level OLIF and 45 consecutive patients who underwent a single-level ALIF at L2-L5 levels. Radiological measurements included the changes of anterior/posterior disc height, coronal/sagittal disc angle, foramen cross-sectional area (CSA), cage position from the anterior margin of the lower vertebra, fusion rate, and cage subsidence using the serial radiographs and computed tomography preoperatively and at the postoperative 1-year follow-up. Clinical outcomes were assessed by visual analog scale (VAS) for back/leg pain, Oswestry disability index (ODI), and the occurrence of perioperative complications.

RESULTS

The baseline radiological and clinical parameters were similar between the OLIF and ALIF groups (all P > 0.05). At postoperative 1 year, the mean anterior disc height was higher in the OLIF group than the ALIF group (11.4 ± 1.9 mm vs. 9.6 ± 2.6 mm, P = 0.021). The mean sagittal disc angle was also greater in the OLIF group than the ALIF group (10.9 ± 4.4° vs. 8.9 ± 5.8°, P < 0.001). The mean cage position was 5.8 ± 2.1 mm in the OLIF group and 8.7 ± 2.3 mm in the ALIF group (P <  0.001). There was no difference in the postoperative changes of coronal disc angles, foramen CSA, fusion rate, cage subsidence, VAS for back/leg pain, ODI, and the occurrence of perioperative complications between the OLIF and ALIF groups (all P > 0.05).

CONCLUSIONS

OLIF showed a greater increase in disc height and segmental lordosis than ALIF with comparable complications. OLIF is a meaningful progress from ALIF.

Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5-S1: case series and review of the literature

OBJECTIVE

Nerve root injuries associated with anterior lumbar interbody fusion (ALIF) are uncommonly reported in the literature. This case series and review aims to describe the etiology of L5 nerve root injury following ALIF at L5-S1.

METHODS

The authors performed a single-center retrospective review of prospectively collected data of patients who underwent surgery between 2017 and 2019 who had postoperative L5 nerve root injuries after stand-alone L5-S1 ALIF. They also reviewed the literature with regard to nerve root injuries after ALIF procedures.

RESULTS

The authors report on 3 patients with postoperative L5 radiculopathy. All 3 patients had pain that improved. Two of the 3 patients had a neurological deficit, one of which improved.

CONCLUSIONS

Stretch neuropraxia from overdistraction is an important cause of postoperative L5 radiculopathy after L5-S1 ALIF. Judicious use of implants and careful preoperative planning to determine optimal implant sizes are paramount.

The Feasibility of Anterior Spinal Access: The Vascular Corridor at the L5-S1 Level for Anterior Lumbar Interbody Fusion

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To analyze the feasibility of anterior spinal access to the vascular corridor at the L5-S1 junction, by evaluating three crucial anatomical landmarks. This provides a framework for risk-stratification for the clinician during preoperative evaluation.

SUMMARY OF BACKGROUND DATA

The anterior lumbar interbody fusion (ALIF) offers many advantages for fusion at the L5-S1 junction. However, the variant iliac vasculature may preclude safe anterior access.

METHODS

Five hundred magnetic resonance imaging (MRI) images of the L5-S1 level were identified, with 379 meeting inclusion criteria. We graded the anterior access into three grades, namely, easy, advanced, or difficult by looking at three important anatomical landmarks-the vascular corridor (narrow if ≤25 mm, medium if 25-35 mm [inclusive], and wide if >35 mm), the left common iliac vein (LCIV) location (grades A-D based on the relative position of the LCIV to the L5-S1 disc space), and the presence or absence of a fat plane.

RESULTS

Our results showed that 43.27% of the patients had wide corridor for the anterior access, 19.26% of patients had no fat plane, and 7.65% had a LCIV that extended past the midline of the disc (Grade C, D: >50%). By combining these three factors, 37.20% would have easy anterior access, while a minority (1.85%) would have a difficult anterior access.

CONCLUSION

The ALIF at L5-S1 offers significant benefits to the patient. The surgeon should be aware of the dangers in an anterior access by looking at three crucial factors to determine whether the access is easy, advanced, or difficult. Patients with a difficult access should be attempted by experts, vascular access surgeons, or consider an alternative approach to L5-S1.Level of Evidence: 3.

Revision Surgery of Total Lumbar Disk Replacement: Review of 48 Cases

STUDY DESIGN

This was a retrospective clinical review.

OBJECTIVE

The objective of this study was to analyze failure mechanisms after total lumbar disk replacement (TDR) and surgical revision strategies in patients with recurrent low back pain (LBP).

SUMMARY AND BACKGROUND DATA

Several reports indicate that TDR revision surgery carries a major risk and that it should not be recommended. The clinical results of posterior instrumented fusion using the prosthesis like an interbody cage have not been well analyzed.

MATERIALS AND METHODS

From 2003 to 2018, 48 patients with recurrent LBP after TDR underwent revision surgery. The average age was 39 years (24-61 y). The mean follow-up was 100.4 months (24.6-207.7 mo). Clinical data, self-assessment of patient satisfaction, and Oswestry Disability Index collected at each clinical control or by phone call for the older files and radiologic assessments were reviewed. The surgical revision strategy included posterior fusion in 41 patients (group A) and TDR removal and anterior fusion in 7 patients (group B), of which 6 patients had an additional posterior fixation.

RESULTS

Facet joint osteoarthritis was associated with TDR failure in 85%. In 68% the position of the prosthesis was suboptimal. Range of motion was preserved in 25%, limited in extension in 65%, and limited in flexion in 40%. Limited range of motion and facet joint osteoarthritis were significantly related (P=0.0008). The complication rate in group B was 43% including iliac vein laceration. Preoperative and 2-year follow-up Oswestry Disability Index were 25.5 and 22.0, respectively, in group A versus 27.9 and 21.3 in group B.

CONCLUSIONS

Posterior osteoarthritis was the principal cause of recurrent LBP in failed TDR. The anterior approach for revision carried a major vascular risk, whereas a simple posterior instrumented fusion leads to the same clinical results.

LEVEL OF EVIDENCE

Level IV.

Retroperitoneal Exposure of the Anterior Lumbar Spine

BACKGROUND

Anterior lumbar spine procedures such as anterior lumbar interbody fusion (ALIF) are used commonly to treat multiple pathologies, including pseudoarthrosis and degenerative disk disease. It is generally a safe and effective procedure, but an anterior approach to the lumbar spine requires critical navigation of the surgical window to avoid delicate structures. An operative technique should maximize the exposure without an increased risk of iatrogenic injury.

OBJECTIVE

To describe in detail a retroperitoneal exposure of the anterior lumbar spine.

METHODS

This surgical approach is a unique variation of standard anterior lumbar spine exposure techniques. This technique is described and illustrated in detail with an accompanying Supplemental Digital Content: video. Institutional Review Board (IRB) approval was not required because this is a variation of current techniques. Patient consent was obtained for the procedure and use of operative pictures and videos.

RESULTS

Precise details of the technique are described. The surgical video demonstrates the technique for the L5-S1 ALIF approach.

CONCLUSION

This technique is a novel variation of the standard retroperitoneal exposure of the anterior lumbar spine. The incision placement, size, and dynamic blunt retraction of this approach limit tissue disruption and provide an efficient exposure that has not been previously described in the literature.

Vascular anatomy and surgical approach in oblique lateral interbody fusion at lumbosacral transitional vertebrae

BACKGROUND

Oblique lateral interbody fusion (OLIF) at lumbosacral junction is typically performed on the central window between the bifurcations of iliac vessels. However, the central window of lumbosacral transitional vertebrae (LSTVs) is usually obstructed by the iliocaval venous structures. We aimed to describe the vascular anatomy and surgical approach in OLIF at LSTVs compared with those in OLIF at typical L5-S1 junction.

METHODS

Sixty-eight consecutive patients who underwent OLIF at lumbosacral junction were included. Of these, 31 patients had LSTVs and 37 patients had typical L5-S1 junction. The position of the iliocaval junction and the configuration of the left common iliac vein were compared using the preoperative CT and MR images of the lumbar spine. The surgical approach and intraoperative vascular findings were analyzed.

RESULTS

Almost 70% of LSTVs had the iliocaval junction at low or very low position. Mobilization of left common iliac vein for central window was potentially difficult in almost 74% of OLIF at LSTVs while it was not required or was potentially easy in almost 80% of OLIF at typical L5-S1. Vascular injury was identified in 2 (6.5%) patients with OLIF at LSTVs and in 3 (8.1%) patients with OLIF at typical L5-S1 junction (P = 0.904).

CONCLUSIONS

In our series, OLIF at LSTVs was performed through lateral window in 93.5% of the cases. Preoperative evaluation of the iliocaval junction using CT/MR of lumbar spine was reliable and valid in the determination of OLIF approach at lumbosacral junction.

Introducing V-Line as a New Strategy to Choose Surgical Corridor in Oblique Lumbar Interbody Fusion at the L5-S1 Segment

Purpose

A retrospective imaging study assessing the availability of oblique lumbar interbody fusion at the level of L5-S1 (OLIF51) and to choose ideal surgical corridor in OLIF51 by introducing V-line.

Methods

The axial views through the center of L5-S1 disc were reviewed. We adopt 18 mm as the width of the simulated surgical corridor. The midline of the surgical corridor is at the center of L5-S1 disc. According to the traction distance of the left iliac vein (LCIV) and psoas major (PM), we defined all the subjects as V (+) (traction-difficultly LCIV), V (-) (traction-friendly LCIV), P (+) (traction-difficultly PM), and P (-) (traction-friendly PM). V-line was defined as a straight line dividing equally the simulated surgical corridor. All cases were divided into 2 groups: The V-line (+) group, more than half of the LCIV region, is located in the ventral part of V-line; the V-line (-) group, more than half of the LCIV region, is located in the dorsal part of V-line. Multiple variables regressive analysis was conducted to analyze the independent risk factors of V-line (+).

Results

V-line (+) was found in 36 (38.7%) patients and V-line (-) in 57 (61.3%). Incidence of V (+) and P (+) was 35.4% (33/93) and 30.1% (28/93), respectively. 16.1% (15/93) subjects processed V (+) and P (+) at the same time. The independent risk factor of V-line (+) were gender of male (P = 0.034, OR: 12.152) and medial position of LCIV (P < 0.001, OR: 265.085). High iliac crest was a significant independent protective factor (P = 0.001, OR: 0.750).

Conclusions

Most patients were suitable for OLIF51. V-line could assess the injury risk of LCIV. For patients who are V-line (+), mainly among males having the LCIV near the midline or the iliac crest relatively low, a surgical corridor external to the LCIV should be taken into consideration.

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.

Comparison of Different Approaches in Lumbosacral Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007–2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.