Video-assisted versus open anterior lumbar spine fusion surgery: a comparison of four techniques and complications in 135 patients

Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note

BACKGROUND

Increasingly there is an impetus on the part of surgeons to find more minimally invasive approaches to treat spinal pathologies. Retroperitoneal prepsoas and transpsoas approaches to the lumbar spine are one such example gaining increased attention. Endoscope-assisted approaches may help further reduce soft tissue dissection.

OBJECTIVE

To describe an endoscope-assisted lateral retroperitoneal prepsoas approach for lumbar diskectomy.

METHODS

Two fresh-frozen thoracolumbar cadaveric specimens were obtained and placed in the right lateral decubitus position. Using a left-sided, retroperitoneal prepsoas approach to the lumbar spine and under endoscopic visualization, diskectomies were performed at the L2/3, L3/4, L4/5, and L5/S1 intervertebral spaces. Qualitative assessment of the extent of central and contralateral foraminal decompression was performed.

RESULTS

The endoscope was found to provide effective visualization at all disk spaces and combined with the anterior retroperitoneal prepsoas approach allowed for effective decompression of all explored disk spaces. Both operators noted difficulty obtaining visualization of the ipsilateral foramen, but adequate central and contralateral foraminal decompression was achievable for central, paracentral, and contralateral far lateral disk protrusions.

CONCLUSION

Endoscope assistance may improve visualization of the lumbar intervertebral disk spaces during retroperitoneal prepsoas approaches and thereby help to expand the surgical indication for anterior and oblique lumbar interbody fusion.

Clinical presentation and surgical anatomy of sympathetic nerve injury during lumbar spine surgery: a narrative review

BACKGROUND AND OBJECTIVE

To highlight the surgical anatomy, procedural variations, presentation, and management of sympathetic nerve injury after surgery of the lumbar spine.

METHODS

PubMed and Google Scholar were searched for publications that were completed between 1951 and 2021. Relevant full-text articles published in the English language were selected and critically reviewed.

KEY CONTENT AND FINDINGS

Sympathetic injury is a highly variable postsurgical complication with a greater incidence after an anterior or oblique approach to the lumbar spine compared to posterior and lateral approaches. The direct and extreme lateral approaches reduce the need to disturb sympathetic nerves thus reducing the risk of complications. It can present in multiple manners, including complex regional pain syndrome (CRPS) and retrograde ejaculation. These complications can be transient and resolve spontaneously or be treated with medications, physical therapy, and spinal blocks. The severity of the conditions and extent of recovery can vary drastically, with some patients never fully recovering.

CONCLUSIONS

To access the lumbar spine, there are operational approaches and techniques that should be used to decrease the risk of intraoperative injury. It is crucial to understand the advantages and risks to different approaches and take the necessary steps to minimize complications. Early identification of dysfunction and adequate management of symptoms are imperative to effectively manage patients with lumbar sympathetic trunk and sympathetic nerve fiber injuries.

Is there a variance in complication types associated with ALIF approaches? A systematic review

Purpose

Anterior lumbar interbody fusion (ALIF) is a well-established alternative to posterior-based interbody fusion techniques, with approach variations, such as retroperitoneal, transperitoneal, open, and laparoscopic well described. Variable rates of complications for each approach have been enumerated in the literature. The purpose of this study was to elucidate the comparative rates of complications across approach type.

Methods

A systematic review of search databases PubMed, Google Scholar, and OVID Medline was made to identify studies related to complication-associated ALIF. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare intraoperative and postoperative complications with ALIF for each approach.

Results

A total of 4575 studies were identified, with 5728 patients across 31 studies included for review following application of inclusion and exclusion criteria. Meta-analysis demonstrated the transperitoneal approach resulted in higher rates of retrograde ejaculation (RE) (p < 0.001; CI = 0.05–0.21) and overall rates of complications (p = 0.05; CI = 0.00–0.23). Rates of RE were higher at the L5/S1 intervertebral level. Rates of vessel injury were not significantly higher in either approach method (p = 0.89; CI =  − 0.04–0.07). Rates of visceral injury did not appear to be related to approach method. Laparoscopic approaches resulted in shorter inpatient stays (p = 0.01).

Conclusion

Despite the transperitoneal approach being comparatively underpowered, its use appears to result in a significantly higher rate of intraoperative and postoperative complications, although confounders including use of bone morphogenetic protein (BMP) and spinal level should be considered. Laparoscopic approaches resulted in shorter hospital stays; however, its steep learning curve and longer operative time have deterred surgeons from its widespread adaptation.

Management of Vascular Complications during Anterior Lumbar Spinal Surgery Using Mini-Open Retroperitoneal Approach

BACKGROUND

Anterior retroperitoneal spine exposure has become increasingly performed for the surgical treatment of various spinal disorders. Despite its advantages, the procedure is not riskless and can expose to potentially life-threatening vascular lesions. The aim of this review is to report the vascular lesions that can happen during anterior lumbar spinal surgery using mini-open retroperitoneal approach and to describe their management.

METHODS

A systematic literature search was performed according to PRISMA to identify studies published in English between January 1980 and December 2019 reporting vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal approach. Three authors independently conducted the literature search on PubMed/Medline database using a combination of the following terms: "spinal surgery", "anterior lumbar surgery (ALS)", "anterior lumbar interbody fusion (ALIF)", "lumbar total disc replacement", "artificial disc replacement", "vascular complications", "vascular injuries". Vascular complications were defined as any peri-operative or post-operative lesions related to an arterial or venous vessel. The management of the vascular injury was extracted.

RESULTS

Fifteen studies fulfilled the inclusion criteria. Venous injuries were observed in 13 studies. Lacerations and deep venous thrombosis ranged from 0.8% to 4.3% of cases. Arterial lesions were observed in 4 studies and ranged from 0.4% to 4.3% of cases. It included arterial thrombosis, lacerations or vasospasms. The estimated blood loss was reported in 10 studies and ranged from 50 mL up to 3000 mL. Vascular complications were identified as a cause of abortion of the procedure in 2 studies, representing respectively 0.3% of patients who underwent ALS and 0.5% of patients who underwent ALIF.

CONCLUSION

Imaging pre-operative planning is of utmost importance to evaluate risk factors and the presence of anatomic variations in order to prevent and limit vascular complications. Cautions should be taken during the intervention when manipulating major vessels and routine monitoring of the limb oxygen saturation should be systematically performed for an early detection of arterial thrombosis. The training of the surgeon access remains a key-point to prevent and manage vascular complications during anterior lumbar spinal surgery with mini-open retroperitoneal.

[Research progress of ureteral injury in oblique lumbar interbody fusion]

Objective

To summarize the research progress of ureteral injury in oblique lumbar interbody fusion (OLIF).

Methods

The literature about incidence, clinical manifestations, diagnosis, and treatment of ureteral injury complications in OLIF was reviewed.

Results

OLIF surgery poses a risk of ureteral injury because its surgical approach is anatomically adjacent to the left ureter. Ureteral injuries in OLIF are often insidious and have no specific clinical manifestations. CT urography is a common diagnostic method. The treatment of ureteral injury depends on a variety of factors such as the time of diagnosis, the location and degree of injury, and the treatment methods range from endoscopic treatment to replacement reconstruction.

Conclusion

Surgeons should pay attention not to damage the ureter and find the abnormality in time during OLIF. High vigilance of abnormalities is conducive to the early diagnosis of ureteral injury. Furthermore, it is important to be familiar with ureter anatomy and gentle operation to prevent ureteral injury.

Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome

Objective

Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy.

Methods

Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months.

Results

The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected.

Conclusion

The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior load-bearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.

Sexual activity after spine surgery: a systematic review

INTRODUCTION

Sexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery. Our aim was to perform a systematic review to collate evidence regarding the impact of spine surgery on sexual function.

METHODS

A systematic review of studies reporting measures of sexual function, and incidence of adverse sexual outcomes (retrograde ejaculation) after major spine surgery was done, regardless of spinal location. Pubmed (MEDLINE) and Google Scholar databases were queried using the following search words "Sex", "Sex life", "Sexual function", "Sexual activity", "retrograde ejaculation", "Spine", "Spine surgery", "Lumbar surgery", "Lumbar fusion", "cervical spine", "cervical fusion", "Spinal deformity", "scoliosis" and "Decompression". All articles published between 1997 and 2017 were retrieved from the database. A total of 81 studies were included in the final review.

RESULTS

Majority of the studies were retrospective case series and were low quality (Level IV) in evidence. Anterior lumbar approaches were associated with a higher incidence of retrograde ejaculation, especially with the utilization of transperitoneal laparoscopic approach. There is inconclusive evidence on the preferred sexual position following fusion, and also on the impact of BMP-2 usage on retrograde ejaculation/sexual dysfunction.

CONCLUSION

Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery. Future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers. These slides can be retrieved under Electronic Supplementary Material.

Minimally invasive anterior, lateral, and oblique lumbar interbody fusion: a literature review

Lumbar interbody fusion involves insertion of a structural graft into an intervertebral disc space to promote bony arthrodesis. It is a well-established surgical strategy for multiple spinal disorders ranging from degenerative conditions to trauma, neoplastic diseases, and deformities requiring correction. Since the inception of lumbar interbody fusion, the most established techniques have been two posterior approaches, the posterior lumbar interbody fusion (PLIF) and the transforaminal lumbar interbody fusion (TLIF). Within the past 15 years, multiple anterolateral approaches to the spine have become widely adopted. These approaches can be performed minimally invasively and spare disruption of the paraspinal muscles and posterior spinal column while enabling wide exposure of the disc space for insertion of interbody grafts much larger than PLIF and TLIF instrumentation. This review highlights three minimally invasive anterolateral approaches: the anterior lumbar interbody fusion (ALIF), the transpsoas lateral lumbar interbody fusion (LLIF), and prepsoas or anterior to the psoas oblique lumbar interbody fusion (OLIF). Relevant topics for discussion and comparison include patient selection, surgical techniques, outcomes, and complications for the three surgical approaches.

Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation: A Retrospective Study With 2-year Follow-up

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to evaluate the clinical and radiological outcomes of mini-open ALIF (MO-ALIF) with self-anchored stand-alone cages for the treatment of lumbar disc herniation in comparison with transforaminal lumbar interbody fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

METHODS

This study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n = 42) or TLIF (n = 40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

RESULTS

Patients who underwent TLIF had a significantly higher volume of blood loss (295.2 ± 81.4 vs. 57.0 ± 15.2 mL) and longer surgery time (130.7 ± 45.1 vs. 60.4 ± 20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group.

CONCLUSION

MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

LEVEL OF EVIDENCE

3.

Anterior Lumbar Interbody Fusion With and Without an "Access Surgeon": A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to investigate the outcomes of anterior lumber interbody fusion (ALIF) with and without an "access surgeon."

SUMMARY OF BACKGROUND DATA

Anterior approaches for spine operations have become increasingly popular but may often involve unfamiliar anatomy and territory for spine surgeons, potentially placing the patient at risk to a greater proportion of approach-related complications. Thus, many spine surgeons require or prefer the assistance of an "access surgeon" to perform the exposure. However, there has been much debate about the necessity of an "access surgeon."

METHODS

A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Meta-analysis was used to pool overall rates, and compare the outcomes of ALIF with an access surgeon and without.

RESULTS

A total of 58 (8028 patients) studies were included in this meta-analysis. The overall intraoperative complications were similar with and without an "access surgeon." The overall pooled rate of arterial injuries [no access 0.44% vs. access 1.16%, odds ratio (OR) 2.67, P < 0.001], retrograde ejaculation (0.41% vs. 0.96%, OR 2.34, P = 0.005), and ileus (1.93% vs. 2.26%, OR 2.45, P < 0.001) was higher with an "access surgeon." However, the overall pooled rates of peritoneal injury (0.44% vs. 0.16%, OR 0.36, P = 0.034) and neurological injury (0.99% vs. 0.11%, OR 0.11, P < 0.001) were lower with an "access surgeon." Total postoperative complications (5.95% vs. 4.08%, OR 0.67, P < 0.001) were lower with an "access surgeon" along with prosthesis complications (1.59% vs. 0.89%, OR 0.56, P < 0.001) and reoperation rates (2.28% vs. 1.31%, OR 0.57, P < 0.001).

CONCLUSION

Compared with no access surgeon, the use of an access surgeon was associated with similar intraoperative complication rates, higher arterial injuries, retrograde ejaculation, ileus, and lower prosthesis complications, reoperation rates, and postoperative complications. In cases wherein exposure may be difficult, support from an "access surgeon" should be available.

LEVEL OF EVIDENCE

1.

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

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

Surgical options for lumbar spinal stenosis

BACKGROUND

Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear.

OBJECTIVES

To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates.

SEARCH METHODS

Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews.

SELECTION CRITERIA

This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'.

AUTHORS' CONCLUSIONS

The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.

Minimally invasive thoracoscopic approach to thoracolumbar junction fractures

AIMS

A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column.

METHODS

Between 2002 and 2014, a total of 176 patients were treated by this technique. The patients received either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone.

RESULTS

In the anterior procedure, the average operative time was 90 min. (50 to 130 min). Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at two years follow-up.

CONCLUSION

The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.

Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications

BACKGROUND CONTEXT

The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated.

PURPOSE

To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to decrease complication rates.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to identify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally invasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category.

RESULTS

Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or revision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit.

CONCLUSIONS

Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.

Retrograde ejaculation following single-level anterior lumbar surgery with or without recombinant human bone morphogenetic protein-2 in 5 randomized controlled trials: clinical article

OBJECT

The aim of this study was to determine the incidence and assess specific risk factors in the postoperative development of retrograde ejaculation (RE) in men treated for degenerative lumbar disc disease at the L4-5 or L5-S1 level with stand-alone anterior interbody implants with or without recombinant human bone morphogenetic protein-2 (rhBMP-2).

METHODS

Patients enrolled in 5 prospective, randomized, multicenter FDA-approved investigational device exemption studies were observed for a minimum of 2 years to assess the rate of RE. Five hundred eight men with symptomatic single-level lumbar degenerative disc disease with up to Grade 1 spondylolisthesis underwent anterior lumbar interbody surgery with stand-alone anterior implants at either L4-5 or L5-S1. All patient self-reported and physician-documented adverse events were recorded over the entire course of follow-up. In the investigational groups, 207 patients were treated with an open surgical procedure using dual paired constructs and rhBMP-2 on an absorbable collagen sponge. The control groups (n = 301) were treated with lumbar fusion cage implants and iliac crest autograft or a metal-on-metal disc arthroplasty device. Multivariate analyses of RE were performed to assess the influence of treatment (rhBMP-2), surgical approach, and treated level. Data were analyzed for each trial individually and for the data pooled from the 5 trials.

RESULTS

Retrograde ejaculation occurred at the highest rates in the earliest clinical trial. Of the 146 men, 6 (4.1%) developed RE postoperatively. In subsequent studies, the rates of RE ranged from 0% to 2.1%. Combining the data from the 5 trials, RE was reported in 7 (3.4%) of the 207 patients who received the rhBMP-2 treatment compared with 5 (1.7%) of the 301 patients who received the autograft or lumbar disc treatment (p = 0.242, Fisher exact test). Cases of RE were reported in 7 (1.6%) of 445 patients who underwent a retroperitoneal spinal exposure; 5 RE cases were reported in 58 patients (8.6%) who underwent a transperitoneal approach. The difference in surgical approaches was significant (p = 0.007, Fisher exact test). There was no difference in the rate of RE based on the lumbar level exposed (p = 0.739). Multivariate analyses were consistent with the conclusions from Fisher exact tests. In the initial rhBMP-2 trial, after adjusting for effects of surgical approach and treated level, the difference in RE between the treatment groups (rhBMP-2 vs autograft or disc arthroplasty) was not significant (p = 0.177); however, the difference in RE between the retroperitoneal and transperitoneal approaches was significant (p = 0.029).

CONCLUSIONS

In these 5 prospective randomized trials involving anterior lumbar interbody surgery, the use of rhBMP-2 was associated with a higher incidence of RE (3.4% vs 1.7%) but did not reach statistical significance. Based on surgical approach, the difference in rates of RE was statistically significant. This study reports on the outcomes of 5 prospective randomized FDA-approved investigational device exemption trials. Registration for studies became law in 2007. Four of these trials were completed before the law went into effect. The registration number for the lumbar disc arthroplasty trial is NCT00635843.

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases

PURPOSE

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution.

METHODS

This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20-80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision.

RESULTS

Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction.

CONCLUSIONS

Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.

Complication avoidance and management in anterior lumbar interbody fusion

The goal of this study was to review the literature to compare strategies for avoiding and treating complications from anterior lumbar interbody fusion (ALIF), and thus provide a comprehensive aid for spine surgeons. A thorough review of databases from the US National Library of Medicine and the National Institutes of Health was conducted. The complications of ALIF addressed in this paper include pseudarthrosis and subsidence, vascular injury, retrograde ejaculation, ileus, and lymphocele (chyloretroperitoneum). Strategies identified for improving fusion rates included the use of frozen rather than freeze-dried allograft, cage instrumentation, and bone morphogenetic protein. Lower cage heights appear to reduce the risk of subsidence. The most common vascular injury is venous laceration, which occurs less frequently when using nonthreaded interbody grafts such as iliac crest autograft or femoral ring allograft. Left iliac artery thrombosis is the most common arterial injury, and its occurrence can be minimized by intermittent release of retraction intraoperatively. The risk of retrograde ejaculation is significantly higher with laparoscopic approaches, and thus should be avoided in male patients. Despite precautionary measures, complications from ALIF may occur, but treatment options do exist. Bowel obstruction can be treated conservatively with neostigmine or with decompression. In cases of postoperative lymphocele, resolution can be attained by creating a peritoneal window. By recognizing ways to minimize complications, the spine surgeon can safely use ALIF procedures.

Vertebrectomy and expandable cage placement via a one-stage, one-position anterolateral retroperitoneal approach in L5 tumors

Spinal reconstruction of the L5 vertebrae after tumor resection remains a challenge. Complex resection followed by circumferential fixation in the same setting, or in staged fashion, is often employed. The added operative time associated with this method potentially increases morbidity and mortality in an inherently high-risk procedure and anatomy in the lumbosacral area makes reconstruction more challenging. The authors describe a technique involving L5 vertebrectomy, placement of an expandable cage, and anterolateral L4-S1 screw fixation via a one-stage, one-position, anterolateral retroperitoneal approach. Two illustrative cases are presented along with the authors overall experience in L5 tumor operations. We believe that this is a feasible reconstructive option after tumor resection in lower lumbar metastatic spine disease. The approach may be also utilized in combined anteroposterior (two-stage) procedures in primary malignant tumors or oligometastatic disease.

Perforation of the sigmoid colon due to intradiscal spacer dislocation

A case of late dislocation of a disc spacer L5/S1 with perforation of the sigmoid colon and transanal passage 4 years after implantation is reported. The objective is to describe an uncommon complication of anterior endoscopic spondylodesis L5/S1. To our knowledge, this is the first report on this rare complication. A 39-year-old patient suffering from a spondylolisthesis L5/S1 (Meyerding grade 2) with bilateral lysis L5 was operated with posterior instrumentation L5/S1 and anterior endoscopic insertion of two disc spacers. 4 years after surgery the patient noticed one of the spacers in the toilet. Radiographic examination of the colon with contrast dye revealed a perforation at the distal sigmoid colon. At the lumbosacral junction there was a bony defect at the site of the absent spacer and an anterior dislocation of the second spacer. A partial resection of the colon at the perforation site with end-to-end anastomosis was performed. The second spacer was removed, and the defect was packed with autologous cancellous bone and local antibiotics. The further course was uneventful. 2 weeks postoperatively the patient was discharged without signs of infection. The radiographic examination after 6 months showed healing of the bone graft with bony fusion L5/S1. In case of incomplete or absent bony fusion the dislocation of intradiscal spacers may arise even years after the primary surgery. In consequence periodical radiographic examinations of spinal instrumentations are recommended until complete bony fusion occurred. Unclear abdominal symptoms following anterior spine surgery require immediate examination.

Retroperitoneal lymphocele after lumbar total disc replacement: a case report and review of literature

BACKGROUND

Retroperitoneal lymphoceles (RPLs) caused by injury to the lymphatics are commonly seen after pelvic lymphadenectomy, renal transplantation, and gynecologic tumor resection surgeries. Degenerative disc disease still remains the major cause of low-back pain. Anterior lumbar spinal procedures, such as anterior lumbar interbody fusion and anterior lumbar arthroplasty, have been increasingly performed for treatment of axial back pain. RPLs, as an approach-related complication, though infrequent, have been reported after anterior lumbar spinal surgery. We report a case of RPL after total disc replacement of the lumbar spine. To our knowledge, there has been no prior report of RPL after total disc replacement managed by percutaneous aspiration only.

METHODS

A 49-year-old woman who underwent total disc replacement at the L4-5 level presented with a postoperative complication of RPL. The imaging findings, clinical course, and treatment are discussed, and a review of literature is presented.

RESULTS

The patient presented with significant abdominal swelling and discomfort at 4 weeks after surgery without any signs or symptoms of infection. Investigations showed an RPL. She was treated by multiple aspirations under ultrasound guidance. At 12 months' follow-up, the patient had no further abdominal symptoms and had gone back to her routine activities and work with significant improvement in back pain.

CONCLUSIONS

RPL is an uncommon complication after anterior lumbar surgery and can be managed effectively if detected and diagnosed early. Although repeated aspiration is associated with high recurrence and infection, it is a safe and minimally invasive procedure to manage RPL.

Minimally invasive versus open transforaminal lumbar interbody fusion

Background

Available clinical data are insufficient for comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). To date, a paucity of literature exists directly comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). The purpose of this study was to directly compare safety and effectiveness for these two surgical approaches.

Materials and Methods

Open or minimally invasive TLIF was performed in 63 and 76 patients, respectively. All consecutive minimally invasive TLIF cases were matched with a comparable cohort of open TLIF cases using three variables: diagnosis, number of spinal levels, and history of previous lumbar surgery. Patients were treated for painful degenerative disc disease with or without disc herniation, spondylolisthesis, and/or stenosis at one or two spinal levels. Clinical outcome (self-report measures, e.g., visual analog scale (VAS), patient satisfaction, and MacNab's criteria), operative data (operative time, estimated blood loss), length of hospitalization, and complications were assessed. Average follow-up for patients was 37.5 months.

Results:

The mean change in VAS scores postoperatively was greater (5.2 vs. 4.1) in theopen TLIF patient group (P = 0.3). MacNab's criteria score was excellent/good in 67% and 70% (P = 0.8) of patients in open and minimally invasive TLIF groups, respectively. The overall patient satisfaction was 72.1% and 64.5% (P = 0.4) in open and minimally invasive TLIF groups, respectively. The total mean operative time was 214.9 min for open and 222.5 min for minimally invasive TLIF procedures (P = 0.5). The mean estimated blood loss for minimally invasive TLIF (163.0 ml) was significantly lower (P < 0.0001) than the open approach (366.8 ml). The mean duration of hospitalization in the minimally invasive TLIF (3 days) was significantly shorter (P = 0.02) than the open group (4.2 days). The total rate of neurological deficit was 10.5% in the minimally invasive TLIF group compared to 1.6% in the open group (P = 0.02).

Conclusions:

Minimally invasive TLIF technique may provide equivalent long-term clinical outcomes compared to open TLIF approach in select population of patients. The potential benefit of minimized tissue disruption, reduced blood loss, and length of hospitalization must be weighted against the increased rate of neural injury-related complications associated with a learning curve.

Sex life and sexual function in men and women before and after total disc replacement compared with posterior lumbar fusion

BACKGROUND CONTEXT

Sex life and sexual function may be affected by low back pain (LBP). Sexual dysfunction after anterior lumbar fusion is reported in both men and women, but focus is mainly on impaired male biological function (retrograde ejaculation) as this may cause infertility. This has led to concern as to whether anterior surgery should be employed in men, at least in younger age groups.

PURPOSE

To investigate how chronic low back pain (CLBP) of assumed discogenic origin affects sex life and sexual function in patients considered for surgical treatment, whether this is affected by surgical treatment (total disc replacement [TDR] or posterolateral fusion [PLF]/posterior lumbar interbody fusion [PLIF]), and if so, are there differences between the surgical procedures undertaken.

STUDY DESIGN

A randomized controlled trial comparing TDR and instrumented lumbar spine fusion, performed either as a PLF or PLIF.

PATIENT SAMPLE

One hundred fifty-two patients were included in this randomized controlled trial to compare the effect on CLBP of either TDR via an anterior retroperitoneal approach or instrumented posterior lumbar fusion, PLF or PLIF.

OUTCOME MEASURES

Global assessment of back pain, back pain (visual analog scale [VAS] 0-100), function (Oswestry Disability Index [ODI] 0-100), quality of life (EQ5D [EuroQol] 0-1), and answers on specific sexual function.

METHODS

Outcome was assessed using data from the Swedish Spine Register (SweSpine). In ODI, one question, ODI 8, reflects the impact of back pain on sex life. This question was analyzed separately. Patients also answered a gender-specific questionnaire preoperatively and at the 2-year follow-up to determine any sexual dysfunction regarding erection, orgasm, and ejaculation. Follow-up was at 1 and 2 years.

RESULTS

Before surgery, 34% reported that their sex life caused some extra LBP, and an additional 30% that their sex life was severely restricted by LBP. After surgery, sex life improved in both groups, with a strong correlation to a reduction of LBP. The gender-specific questionnaire used to measure sexual function after 2 years revealed no negative effect of TDR or Fusion in men regarding erection or retrograde ejaculation. However, 26% of all men in the Fusion group, compared with 3% in the TDR group, reported postoperative deterioration in the ability to achieve orgasm, despite a reduction of LBP.

CONCLUSIONS

Impairment of sex life appears to be related to CLBP. An improvement in sex life after TDR or lumbar fusion was positively correlated to a reduction in LBP. Total disc replacement in this study, performed through an anterior retroperitoneal approach, was not associated with greater sexual dysfunction compared with instrumented lumbar fusion performed either as a PLF or as a PLIF. Sexual function, expressed as orgasm, deteriorated in men in the Fusion group postoperatively, in spite of this group reporting less LBP after 2 years.

Thoracoscopy for minimally invasive thoracic spine surgery

Thoracoscopy has been used worldwide for many years by thoracic surgeons. Despite a long learning curve and technical demands of the procedure, thoracoscopy has several advantages, including better cosmesis, adequate exposure to all levels of the thoracic spine from T2 to L 1, better illumination and magnification at the site of surgery, less damage to the tissue adjacent to the surgical field, less morbidity when compared with standard thoracotomy in terms of respiratory problems, pain, blood loss, muscle and chest wall damages, consequent shorter recovery time, less postoperative pulmonary function impairment, and shorter hospitalization. Good results at short- and medium-term follow-up need to be confirmed at long-term follow-up.

Clinical anatomic study of the lower lumbar anterolateral vein: with respect to retroperitoneal endoscopic surgery

OBJECTIVE

To study the anatomy of veins of the lower lumbar spine and provide the anatomic basement for laparoscopic lumbar surgery.

METHODS

A total of 15 formaldehyde-preserved cadavers were studied with special attention to the variety and surrounding structure of ascending lumbar vein (ALV) and iliolumbar veins (ILV), and their relationship with lumbar plexus.

RESULTS

ALV and ILV can be found on every sides, which have four variants including separate entry and common entry. The ascending vein and iliolumbar vein separately enter common iliac vein in 18 cases, and as a common stem enter the common iliac vein in 12 cases. Retracting common iliac vein medially both the ascending lumbar and the iliolumbar veins are always at risk of avulsion on exposure of the disc space. The injury of obturator nerve and lumbosacral trunk of lumbar plexus should be avoided.

CONCLUSION

Awareness of these anatomic variation can prevent the hemorrhage and be helpful for the surgeon in performing a careful ligation of these veins before medial retraction of the common iliac vein. Our findings emphasize the need for proper dissection of ALV and ILV before ligature during exposure of the lower lumbar spine.

Technique and clinical results of minimally invasive reconstruction and stabilization of the thoracic and thoracolumbar spine with expandable cages and ventrolateral plate fixation

OBJECTIVE

To evaluate the techniques of minimally invasive single- and multilevel corpectomy and reconstruction of the thoracic and thoracolumbar spine using expandable vertebral body replacement (VBR) cages and ventrolateral plate fixation (VPF) via anterolateral retropleural (ALRA) and combined thoracoabdominal approaches.

METHODS

38 patients with spondylitis, traumatic or metastatic lesions of thoracic or thoracolumbar vertebrae T4 to L2 underwent spinal decompression and ventral column reconstruction with correction of spinal deformity by VBR and VPF via ALRA or a combined lateral extrapleural/extraperitoneal (extracoelomic) thoracolumbar approach (CLETA). Overall clinical and neurological outcome, operative time, blood loss, reduction of deformity, and postoperative pain were assessed during a mean follow-up period of 22.8 months.

RESULTS

VBR and VPF were carried out successfully without conversion to conventional approaches in all patients. Mean operative time (ALRA, 163 +/- 33 min; CLETA, 175 +/- 39 min), mean blood loss (ALRA, 280 +/- 160 ml; CLETA, 420 +/- 250 ml), average correction (19.3 degrees), loss of correction of sagittal deformity (0.9 degrees), and clinical outcome compare favorably to the results reported for open and endoscopic techniques. Postoperative pain levels (mean visual analog scale score at 24 h, 2.7 +/- 0.9) and the incidence of postoperative pulmonary dysfunction (three out of 38 patients) were low. The average length of stay was 7.4 days. ALRA and CLETA obviate routine chest tube insertion, thus allowing for early postoperative ambulation (average, 1.1 d).

CONCLUSION

Minimally invasive VBR and VPF conducted via minimally invasive approaches (ALRA or CLETA) yields favorable clinical results at least equal to conventional open surgery, with significant reductions in perioperative morbidity and pain, expedited ambulation, and early discharge from the hospital.

PERCUTANEOUS TRANSFORAMINAL LUMBAR INTERBODY FUSION FOR THE TREATMENT OF DEGENERATIVE LUMBAR INSTABILITY

OBJECTIVE

Percutaneous spinal instrumentation techniques may be helpful to reduce approach-related morbidity inherent to conventional open surgery. This article reports technique, clinical outcomes, and fusion rates of percutaneous transforaminal lumbar interbody fixation (pTLIF). Results are compared with those of mini-open transforaminal lumbar interbody fixation (oTLIF) using a muscle splitting (Wiltse) approach.

METHODS

pTLIF was performed in 43 patients with single-level and 10 patients with bi- or multilevel lumbar discopathy or degenerative pseudolisthesis resulting in axial back pain and claudication, pseudoradicular, or radicular symptoms. Decompression, discectomy, and interbody cage insertion were performed through 18-mm tubular retractors followed by percutaneous pedicle screw-rod fixation. Clinical outcome was assessed by early postoperative pain scores (visual analog score) and standardized functional outcome questionnaires (American Academy of Orthopedic Surgeons lumbar spine and Roland-Morris low back pain score). Fusion rates were assessed by thin-slice computed tomographic scan at 16 months. Clinical outcome, time in the operating room, intraoperative blood loss, and postoperative access-site pain were compared with an institutional reference series of 67 oTLIF procedures.

RESULTS

Excellent and good clinical results were obtained in 46 (87%) out of 53 patients at 16 months. The time spent in the operating room was equivalent and the blood loss reduced compared with oTLIF (P < 0.01). There was no morbidity related to instrumentation. Postoperative pain was significantly lower after pTLIF after the second postoperative day (P < 0.01). The overall clinical outcome was not different from oTLIF at 8 and 16 months.

CONCLUSION

pTLIF allows for safe and efficient minimally invasive treatment of single and multilevel degenerative lumbar instability with good clinical results. Further prospective studies investigating long-term functional results are required to assess the definitive merits of percutaneous instrumentation of the lumbar spine.

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability

OBJECTIVES

Multiple different approaches are used to treat lumbar degenerative disc disease and spinal instability. Both anterior-posterior (AP) reconstructive surgery and transforaminal lumbar interbody fusion (TLIF) provide a circumferential fusion and are considered reasonable surgical options. The purpose of this study was to quantitatively assess clinical parameters such as surgical blood loss, duration of the procedure, length of hospitalization, and complications for TLIF and AP reconstructive surgery for lumbar fusion.

METHODS

A retrospective analysis was completed on 167 consecutive cases performed between January 2002 and March 2004. TLIF surgical procedure was performed on 124 patients, including 73 minimally invasive and 51 open cases. AP surgery was performed on 43 patients. Patients were treated for painful degenerative disc disease, facet arthropathy, degenerative instability, and spinal stenosis.

RESULTS

The mean operative time for AP reconstruction was 455 minutes, for minimally invasive TLIF 255 minutes, and open TLIF 222 minutes. The mean blood loss for AP fusion surgery was 550 mL, for minimally invasive TLIF 231 mL, and open TLIF 424 mL. The mean hospitalization time for AP reconstruction was 7.2 days, for minimally invasive TLIF 3.1 days, and open TLIF 4.1 days. The total rate of complications was 76.7% for AP reconstruction, including 62.8% major and 13.9% minor complications. The minimally invasive TLIF patients group had the total 30.1% rate of complications, 21.9% of which were minor and 8.2% major complications. There were no major complications in the open TLIF patients group, with 35.3% minor complications.

CONCLUSIONS

AP lumbar interbody fusion surgery is associated with a more than two times higher complication rate, significantly increased blood loss, and longer operative and hospitalization times than both percutaneous and open TLIF for lumbar disc degeneration and instability.

Biomechanical evaluation of a novel lumbosacral axial fixation device

BACKGROUND

Interbody arthrodesis is employed in the lumbar spine to eliminate painful motion and achieve stability through bony fusion. Bone grafts, metal cages, composite spacers, and growth factors are available and can be placed through traditional open techniques or minimally invasively. Whether placed anteriorly, posteriorly, or laterally, insertion of these implants necessitates compromise of the anulus--an inherently destabilizing procedure. A new axial percutaneous approach to the lumbosacral spine has been described. Using this technique, vertical access to the lumbosacral spine is achieved percutaneously via the presacral space. An implant that can be placed across a motion segment without compromise to the anulus avoids surgical destabilization and may be advantageous for interbody arthrodesis. The purpose of this study was to evaluate the in vitro biomechanical performance of the axial fixation rod, an anulus sparing, centrally placed interbody fusion implant for motion segment stabilization.

METHOD OF APPROACH

Twenty-four bovine lumbar motion segments were mechanically tested using an unconstrainedflexibility protocol in sagittal and lateral bending, and torsion. Motion segments were also tested in axial compression. Each specimen was tested in an intact state, then drilled (simulating a transaxial approach to the lumbosacral spine), then with one of two axial fixation rods placed in the spine for stabilization. The range of motion, bending stiffness, and axial compressive stiffness were determined for each test condition. Results were compared to those previously reported for femoral ring allografts, bone dowels, BAK and BAK Proximity cages, Ray TFC, Brantigan ALIF and TLIF implants, the InFix Device, Danek TIBFD, single and double Harms cages, and Kaneda, Isola, and University plating systems.

RESULTS

While axial drilling of specimens had little effect on stiffness and range of motion, specimens implanted with the axial fixation rod exhibited significant increases in stiffness and decreases in range of motion relative to intact state. When compared to existing anterior, posterior, and interbody instrumentation, lateral and sagittal bending stiffness of the axial fixation rod exceeded that of all other interbody devices, while stiffness in extension and axial compression were comparable to plate and rod constructs. Torsional stiffness was comparable to other interbody constructs and slightly lower than plate and rod constructs.

CONCLUSIONS

For stabilization of the L5-S1 motion segment, axial placement of implants offers potential benefits relative to traditional exposures. The preliminary biomechanical data from this study indicate that the axial fixation rod compares favorably to other devices and may be suitable to reduce pathologic motion at L5-S1, thus promoting bony fusion.

Sexual function in men and women after anterior surgery for chronic low back pain

Sexual dysfunction after anterior lumbar fusion has mainly been focused on male biological function (retrograde ejaculation). The aim of the present study is to assess the effect of fusion surgery for chronic low back pain on the sex-related quality of life. Apart from routine prospective questionnaires, additional gender-specific mailed questionnaires produced retrospective data on sexual enjoyment and function after 2 years of follow-up. Patients randomised to non-surgical treatment and anterior or posterior fusion were compared. We found that surgically treated patients had a significantly better sex life than those non-surgically treated. The improved sex life was significantly associated with the reduced back pain. The improvement after anterior fusion, however, was counteracted by a trend towards disturbed orgasm and genital sensation in women, and a significant disturbance of ejaculation and genital sensation in men. In view of the increased frequency of anterior lumbar surgery with the strong promotion of disc replacement, the findings in the present small retrospective pilot study should be tested in larger prospective trials.