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Pereira Filho ARD, Baptista VS, Mussalem MGVB, Júnior FCFC, Uehara MK, Aguiar NRC, Baston AC, Desideri AV, de Meldau Benites V. Incidence of intraoperative morbidities in anterior lumbar interbody fusion (ALIF): a comprehensive study of 5,299 levels. Neurosurg Rev 2025; 48:327. [PMID: 40138083 DOI: 10.1007/s10143-025-03496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 03/06/2025] [Accepted: 03/22/2025] [Indexed: 03/29/2025]
Abstract
CONTEXT Anterior Lumbar Interbody Fusion (ALIF) is performed via an abdominal approach to remove the intervertebral disc. Although academic reports suggest low intraoperative complication rates, the available data show significant variability. There is a lack of large-scale, robust studies that consistently evaluate the morbidity rates associated with this procedure. OBJECTIVE This study evaluates the operative parameters of this procedure based on a substantial number of cases. STUDY DESIGN A retrospective case series. METHODS Patient data were retrospectively collected from the database of the Instituto de Acessos à coluna Aécio Dias (IAAD). All patients aged 18 years or older who underwent ALIF surgery were included in the study. Patients who underwent other surgical approaches were excluded. Data on intraoperative morbidity (vascular injuries, injuries to intra- and extraperitoneal organs, dural sac injuries, and nerve root injuries), operative time, and blood loss were collected and analyzed. RESULTS A total of 3,438 patients were evaluated. 1,671 (48.6%) were male, and 1,767 (51.4%) were female. The mean age was 47.87 ± 12.10 years, ranging from 18 to 88 years. The reported incidence of complications was as follows: vascular injuries (3.25%), nerve root injuries (0.09%), dural sac injuries (0.06%), and injuries to intra- and extraperitoneal organs (0.03%). CONCLUSIONS ALIF surgery demonstrated safety and low morbidity. A multidisciplinary team, including access surgeons, played a pivotal role in reducing vascular complications, optimizing surgical times, and minimizing blood loss, aligning with the standards reported in the literature.
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Affiliation(s)
| | - Vinicius Santos Baptista
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Szabó V, Berta B, Nagy M, Kulcsár D, Perlaki G, Schwarcz A. The Alternative Approach to the Lumbosacral Segment: The Right-Sided Oblique Lumbar Interbody Fusion Compared with Anterior Lumbar Interbody Fusion. World Neurosurg 2025; 196:123823. [PMID: 39993623 DOI: 10.1016/j.wneu.2025.123823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Revised: 02/14/2025] [Accepted: 02/15/2025] [Indexed: 02/26/2025]
Abstract
BACKGROUND Anterior lumbar interbody fusion with dorsal percutaneous pedicle screw fixation (ALIF+D) is a well-described technique treating lumbosacral degenerative diseases. Mobilizing the common iliac arteries and veins during the ALIF+D approach may increase the risk of bleeding when the bifurcations are low. This study demonstrates that in such cases, the right-sided oblique lumbar interbody fusion with dorsal percutaneous pedicle screw fixation (OLIF+D) offers a novel alternative to the ALIF+D approach. METHODS Twenty-one patients were operated on with the ALIF+D approach, and 20 patients were operated on using the right-sided OLIF+D technique. Computed tomography-based imaging and clinical data, such as patient-reported outcomes, were collected. RESULTS Both ALIF+D and OLIF+D surgeries elicited a statistically significant decrease (P ≤ 0.001) between the preoperative and postoperative Oswestry disability index and the back and leg pain visual analog scale scores. A significant increase was observed in both techniques between preoperative and postoperative anterior segmental height, posterior segmental height, and segmental lordosis (P ≤ 0.001). There were no statistically significant postoperative differences between patients operated by ALIF+D and patients operated by OLIF+D in the segmental lordosis angle (P = 0.354), anterior segmental height (P = 0.297), posterior segmental height (P = 0.404), Oswestry disability index (P = 0.824), or back and leg visual analog scale scores (P = 0.682 and P = 0.979, respectively). The OLIF+D group showed trend-like higher blood loss (198 ± 118 mL vs. 134 ± 77 mL; P = 0.058) and significantly longer surgical time (199 ± 47 vs. 169 ± 54 minutes; P = 0.009) compared to the ALIF+D group. CONCLUSIONS The right-sided lumbosacral OLIF+D approach is an alternative to the ALIF+D approach if the latter is hazardous due to vessel anatomy.
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Affiliation(s)
- Viktor Szabó
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.
| | - Balázs Berta
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Máté Nagy
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Dominik Kulcsár
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Gábor Perlaki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary; Centre for Neuroscience, HUN-REN-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary; Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Attila Schwarcz
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
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Claydon MH, Biddau DT, Claydon AN, Laggoune JP, Malham GM. Incidence of temporary intraoperative iliac artery occlusion during anterior spinal surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 20:100554. [PMID: 39381261 PMCID: PMC11459647 DOI: 10.1016/j.xnsj.2024.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/15/2024] [Accepted: 08/28/2024] [Indexed: 10/10/2024]
Abstract
Background Thromboembolic complications in anterior lumbar spinal surgery can rarely result in limb loss. Iliac vessel retraction can temporarily occlude the iliac artery risking thromboembolic sequelae. Studies estimate the incidence of iliac artery thrombosis at 0.45%. Brief intraoperative heparinization can potentially mitigate this risk. We aim to quantify the incidence of temporary iliac artery occlusion (TIAO) and examine its association with potential risk factors (sex, BMI, target disc level, and type of prosthesis). Methods Retrospective analysis of consecutive patients undergoing anterior lumbar spinal surgery by a single vascular surgeon and 5 spinal neurosurgeons between 2009 and 2022. Patients underwent single or double-level total disc replacement (TDR); single, double, or triple-level anterior lumbar interbody fusion (ALIF); or hybrid procedure (combined cranial TDR and caudal ALIF). A pulse oximeter monitored bilateral second toes perfusion. Loss of the waveform, combined with a nonpalpable external iliac artery pulse distal to the retractors was defined as TIAO of the ipsilateral artery. Heparin was administered if TIAO developed. Results Of 605 patients (318 males, 287 females), TIAO occurred in 176 patients (29.1%). TIAO occurred in 13.5% of the 377 patients who underwent single or multilevel ALIF and in 42.7% of the 110 patients who underwent single or multilevel TDR (p=.004). In single-level surgery at L5/S1, TIAO occurred in 3.1% of patients. In single-level surgery at L4/5, TIAO occurred in 65.2% of patients overall; the rate was higher for TDR than for ALIF (74.6% vs. 48.5%; p=.01). The TIAO rate was 44.3% in multilevel procedures and 66.1% in hybrid procedures. No patient developed postoperative thrombotic iliac artery occlusion or embolic complications. Conclusions TIAO occurred frequently during anterior lumbar exposure (29%). Anterior spinal exposure at L4/5 had a high incidence of TIAO, particularly for TDR, in contrast to L5/S1.
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Affiliation(s)
- Matthew H. Claydon
- Neuroscience Institute, Epworth Hospital, Richmond, Melbourne, Australia
- Spine Surgery Research Foundation, Richmond, Victoria, Australia
| | - Dean T. Biddau
- Neuroscience Institute, Epworth Hospital, Richmond, Melbourne, Australia
- School of Biomedical Science, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Spine Surgery Research Foundation, Richmond, Victoria, Australia
| | | | - Jordan P. Laggoune
- Neuroscience Institute, Epworth Hospital, Richmond, Melbourne, Australia
| | - Gregory M. Malham
- Neuroscience Institute, Epworth Hospital, Richmond, Melbourne, Australia
- Spine Surgery Research Foundation, Richmond, Victoria, Australia
- Spine Surgery Research, Department of Health Science and Biostastics, Swinburne University of Technology, Melbourne, Victoria, Australia
- Department of Medicine and Surgery, University of Melbourne, Parkville, Victoria, Australia
- School of Health Science and Biomedine, RMIT University, Melbourne, Victoria, Australia
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Shao M, Kruse A, Nelson P, Langer DJ, Silverstein JW. Neuromonitoring Identifies Occlusion of Femoral Artery in STA-MCA Bypass Procedure: A Case Report. Neurodiagn J 2023; 63:180-189. [PMID: 37723081 DOI: 10.1080/21646821.2023.2247952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 09/20/2023]
Abstract
Intraoperative neurophysiological monitoring (IONM) is a technique used to assess the somatosensory and gross motor systems during surgery. While it is primarily used to detect and prevent surgically induced nervous system trauma, it can also detect and prevent injury to the nervous system that is the result of other causes such as trauma or ischemia that occur outside of the operative field as a result of malpositioning or other problematic physiologic states. We present a case study where a neuromonitoring alert altered the surgical procedure, though the alert was not correlated to the site of surgery. A 69-year-old male with a history of bilateral moyamoya disease and a left middle cerebral artery infarct underwent a right-sided STA-MCA bypass and encephaloduroarteriosynangiosis (EDAS) with multimodal IONM. During the procedure, the patient experienced a loss of motor evoked potential (MEP) recordings in the right lower extremity. Blood pressure was elevated, which temporarily restored the potentials, but they were lost again after the angiography team attempted to place an arterial line in the right femoral artery. The operation was truncated out of concern for left hemispheric ischemia, and it was later discovered that the patient had an acute right external iliac artery occlusion caused by a fresh thrombus in the common femoral artery causing complete paralysis of the limb. This case highlights the importance of heeding IONM alerts and evaluating for systemic causes if the alert is not thought to be of surgical etiology. IONM can detect adverse systemic neurological sequelae that is not necessarily surgically induced.
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Affiliation(s)
- Miriam Shao
- Department of Neurological Surgery Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Aaron Kruse
- Department of Clinical Neurophysiology Neuro Protective Solutions, New York, New York
| | - Priscilla Nelson
- Department of Anesthesia Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - David J Langer
- Department of Neurological Surgery Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Justin W Silverstein
- Department of Clinical Neurophysiology Neuro Protective Solutions, New York, New York
- Department of Neurology Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
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Finite Element Analysis of a Novel Anterior Locking Plate for Thoracolumbar Burst Fracture. BIOMED RESEARCH INTERNATIONAL 2021; 2021:2949419. [PMID: 34671672 PMCID: PMC8523228 DOI: 10.1155/2021/2949419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022]
Abstract
Purpose The finite element analysis method was used to explore the biomechanical stability of a novel locking plate for thoracolumbar burst fracture fusion fixation. Methods The thoracolumbar CT imaging data from a normal volunteer was imported into finite software to build a normal model and three different simulated surgical models (the traditional double-segment fixation model A, the novel double-segment fixation model B, and the novel single-segment fixation model C). An axial pressure (500 N) and a torque (10 Nm) were exerted on the end plate of T12 to simulate activity of the spine. We recorded the range of motion (ROM) and the maximum stress value of the simulated cages and internal fixations. Results Model A has a larger ROM in all directions than model B (flexion 5.63%, extension 38.21%, left rotation 46.51%, right rotation 39.76%, left bending 9.45%, and right bending 11.45%). Model C also has a larger ROM in all directions than model B (flexion 555.63%, extension 51.42%, left rotation 56.98%, right rotation 55.42%, left bending 65.67%, and right bending 59.47%). The maximum stress of the cage in model A is smaller than that in model B except for the extension direction (flexion 96.81%, left rotation 175.96%, right rotation 265.73%, left bending 73.73%, and right bending 171.28%). The maximum stress value of the internal fixation in model A is greater than that in model B when models move in flexion (20.23%), extension (117.43%), and left rotation (21.34%). Conclusion The novel locking plate has a smaller structure and better performance in biomechanical stability, which may be more compatible with minimally invasive spinal tubular technology.
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Liang Y, Xu S, Zhao Y, Liu H, Mao K. The effects of vertebral rotation on the position of the aorta relative to the spine in patients with adult degenerative scoliosis. Ther Adv Chronic Dis 2021; 12:20406223211027108. [PMID: 34249304 PMCID: PMC8237214 DOI: 10.1177/20406223211027108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
Aims This study aimed to explore the effects of vertebral rotation on the position of the aorta relative to the thracolumbar and lumbar spine, and to identify risk factors for vertebral rotation in patients with adult degenerative scoliosis (ADS). Methods A total of 71 patients with ADS were divided into left scoliosis (LS) group (n = 40 cases) and right scoliosis (RS) group (n = 31cases) with well-matched demographics. Apical vertebrae, Cobb angle (°), coronal horizontal movement, thoracolumbar kyphosis (TLK) and Nash-Moe rotation classification were measured on X-ray. The Cartesian coordinate system was established on T2-MRI for each level of intervertebral disc on thracolumbar and lumbar spine, where aorta-vertebrae angle (α), aorta-vertebrae distance (d), and vertebral rotation angle (γ) for each level of T12-L1 to L3-L4 on MRI were defined within the Cartesian coordinate system. Results There was no statistical difference in the distribution of apical vertebrae between LS and RS groups. Nash-Moe classification was of no significance between the two groups. When there was a larger Cobb angle and coronal horizontal movement, a greater γ in LS group and a lower γ in RS group were noted (both p < 0.001). There was no correlation among γ, α, and d in LS group (p = 0.908 and 0.661, respectively) nor in RS group (p = 0.738 and 0.289, respectively). In LS group, Nash-Moe classification correlated to Cobb angle, coronal movement and TLK. In RS group, it correlated to Cobb angle and coronal movement. Cobb angle was the risk factor for Nash-Moe classification in RS group while no factors were identified in LS group. Coronal movement was independent risk factor for γ (p = 0.003) in LS group. Moreover, γ was affected by Cobb angle (p = 0.001) and coronal horizontal movement (p = 0.006) in RS group. Conclusion Vertebral rotation could be predicted by Cobb angle or coronal horizontal movement measured on X-ray in ADS patients and aorta maintained in a relatively normal position in patients with ADS.
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Affiliation(s)
- Yan Liang
- Peking University People's Hospital, Beijing, China
| | - Shuai Xu
- Peking University People's Hospital, Beijing, China
| | - Yongfei Zhao
- The Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People's Hospital, No. 11. Xi Zhimen South Street, Xi Cheng District, Beijing, 100044, China
| | - Keya Mao
- Orthopedic Department, The Chinese PLA General Hospital (301 Hospital), No. 28. Fu Xing Rd, Hai Dian District, Beijing, 100853, China
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Hofler RC, Fessler RG. Intraoperative Neuromonitoring and Lumbar Spinal Instrumentation: Indications and Utility. Neurodiagn J 2021; 61:2-10. [PMID: 33945449 DOI: 10.1080/21646821.2021.1874207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multimodal intraoperative neurophysiologic monitoring (IONM) can be utilized as an adjunct to lumbar spinal instrumentation in order to aid with avoidance of neurologic complications. The most commonly utilized modalities include somatosensory-evoked potentials, motor-evoked potentials, and electromyography. Somatosensory-evoked potentials (SSEPs) allow for continuous assessment of the dorsal columns of the spinal cord and are therefore most useful during procedures with a posterior approach to the cervical and thoracic spine. Motor-evoked potentials (MEPs) and electromyography (EMG) can be applied intermittently to assess motor nerve function. The utility of each individual modality can be largely dependent on the surgical approach. Approaches to lumbar spinal instrumentation can be generally categorized as anterior, lateral, and posterior. For lateral approaches, electromyography can be helpful in identifying neural structures crossing the surgical field to prevent injury. In posterior and anterior approaches, somatosensory-evoked potentials and motor-evoked potentials can be used to assess nerve injury during and after maneuvers for decompression and instrumentation. Additionally, during the placement of pedicle screws, direct stimulation with triggered electromyography can be used to detect the pedicle cortex's breach. The efficacy of intraoperative neuromonitoring is dependent on prompt and accurate recognition of changes in signals. This is then followed by accurate recognition of the cause for these changes and appropriate responses by the surgeon, anesthesiologist, and monitoring personnel to correct the change.
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Affiliation(s)
- Ryan C Hofler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Pelletier Y, Lareyre F, Cointat C, Raffort J. Management of Vascular Complications during Anterior Lumbar Spinal Surgery Using Mini-Open Retroperitoneal Approach. Ann Vasc Surg 2021; 74:475-488. [PMID: 33549783 DOI: 10.1016/j.avsg.2021.01.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/10/2021] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Yann Pelletier
- Orthopedic Department, IULS (Institut Universitaire Locomoteur & du sport), University Hospital of Nice, Nice, France
| | - Fabien Lareyre
- Université Côte d'Azur, CHU, Inserm, C3M, Nice, France; Department of Vascular Surgery, Hospital of Antibes Juan-les-Pins, Antibes, France.
| | - Caroline Cointat
- Orthopedic Department, IULS (Institut Universitaire Locomoteur & du sport), University Hospital of Nice, Nice, France
| | - Juliette Raffort
- Université Côte d'Azur, CHU, Inserm, C3M, Nice, France; Department of Clinical Biochemistry, University Hospital of Nice, Nice, France
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Kakadiya DG, Gohil DK, Soni DY, Shakya DA. Clinical, radiological and functional results of transforaminal lumbar interbody fusion in degenerative spondylolisthesis. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 2:100011. [PMID: 35141582 PMCID: PMC8819860 DOI: 10.1016/j.xnsj.2020.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Purpose To evaluate the clinical, functional and radiographic outcomes of transforaminal lumbar interbody fusion (TLIF) in degenerative low-grade spondylolisthesis. Materials and Methods A prospective observational study of 120 consecutive patients (M:F = 24:96) with spondylolisthesis operated with TLIF. Clinical and functional outcome was assessed on Visual analogue Scale (VAS) and Oswestry Disability Index(ODI). The radiological outcome was assessed on sagittal alignment at a specific level, radiologic bony fusion/non-union, intervertebral disc heights and percentage of a slip in relation to the endplate. Clinical and radiological data were collected and analysed. Results The mean age was 50.97 years. The average follow-up was 14.5 months (12 to 18 months). Mean preoperative ODI was 38.73 and postoperatively 21.30. Analysing the radiological fusion with clinical scores, poorer radiological fusion grades correlated with higher VAS scores for pain. 70% of patients achieved >50% reduction in pain and 60% achieved > 30% reduction in ODI. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL) were significantly greater in spondylolisthesis. PI, PT, and SS did not change statistically from the baseline postoperatively but increased LL and Segmental LL (P < 0.001). The results of our study showed a close relation between satisfactory clinical outcome (90%) and solid fusion (80%). There was however a significant number of patients with instrument failure that was found in association with fusion failure. There were no intra-operative complications. Conclusion TLIF is an effective option to achieve circumferential fusion without severe complications. An increased pelvic incidence may be an important factor predisposing to progression in developmental spondylolisthesis. TLIF increases global and segmental LL and provides a satisfactory outcome in symptomatic low-grade degenerative spondylolisthesis.
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Manunga J, Alcala C, Smith J, Mirza A, Titus J, Skeik N, Senthil J, Stephenson E, Alexander J, Sullivan T. Technical approach, outcomes, and exposure-related complications in patients undergoing anterior lumbar interbody fusion. J Vasc Surg 2020; 73:992-998. [PMID: 32707392 DOI: 10.1016/j.jvs.2020.06.129] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/30/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF). METHODS We conducted a retrospective analysis of prospectively collected data on patients undergoing ALIF at our institution from January 2008 to December 2017. Access was performed by a vascular surgeon who remained present for the duration of the case. Data collected included patients' demographics, comorbidities, exposure related complications and ileus. Study end points included major adverse events and minor complications. Major adverse events included any vascular injuries requiring repair, bowel and ureter injuries, postoperative bleeding requiring reoperation, myocardial infarction, stroke, venous thromboembolism (pulmonary embolism/deep venous thrombosis), wound dehiscence, and death. Minor complications included postoperative paralytic ileus, urinary tract infections, and surgical site infections. The incidence of incisional hernia was also evaluated. RESULTS During this period, 1178 patients (514 males and 664 females; mean age, 54.1 ± 13.8 years) underwent a total of 2352 levels ALIF at our institution (single level, 422 patients; 2 levels, 450; 3 levels, 205; 4 levels, 98; 5 levels, 6; 6 levels, 1; and 7 levels, 1). The median estimated blood loss was 25 mL (interquartile range, 25-50). There were 57 exposure-related complications (4.8%), including vascular injuries (venous, 13; arterial, 4) in 17 patients (1.4%), bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Eleven of the 13 venous injuries (84.6%) occurred while exposing the L4 to L5 lumbar level. Two of the four patients with arterial injuries developed acute limb ischemia requiring embolectomy. One embolized to the superior mesenteric artery and underwent bowel resection. Twenty patients (1.7%) developed venous thromboembolism, two of whom had sustained left iliac vein injury during exposure. Sixteen patients (1.4%) developed a retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Thirty-six patients (3.1%) developed postoperative ileus, defined as an inability to tolerate diet on postoperative day 3. Four patients (0.4%) had a postoperative myocardial infarction, and two had a stroke and two (0.17%) died within the first 30 postoperative days. Thirty-one patients developed incisional complications, including surgical site infection in 24 and incisional hernia in 7. CONCLUSIONS Our findings suggest that ALIF exposure can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4 to L5 level and can be safely addressed by an experienced vascular team.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn.
| | | | - Jenna Smith
- Minneapolis Heart Institute Foundation, Minneapolis, Minn
| | - Aleem Mirza
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jessica Titus
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Nedaa Skeik
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jayarajan Senthil
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Elliot Stephenson
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jason Alexander
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
| | - Timothy Sullivan
- Section of Vascular & Endovascular surgery, Minneapolis Heart Institute @ Abbott Northwestern Hospital, Minneapolis, Minn
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The position of the aorta relative to the spine in patients with adult degenerative scoliosis. J Orthop Surg Res 2020; 15:73. [PMID: 32093718 PMCID: PMC7041114 DOI: 10.1186/s13018-020-1578-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/04/2020] [Indexed: 11/30/2022] Open
Abstract
Study design A retrospective analysis was conducted to analyze the position of the aorta by MRI in patients with adult degenerative scoliosis. Objective This study aimed to investigate the relative anatomic positions of the aorta and spine in patients with adult degenerative scoliosis (ADS). Summary of background data Aorta injury is a rare complication of spinal surgeries. However, there would be a disastrous consequence once it happened. Therefore, knowing about the position of aorta is of great importance. Methods A retrospective analysis was performed in 90 patients with ADS and 132 participants without spine deformity. ADS patients were divided into several groups such as left scoliosis, left scoliosis with thoracolumbar kyphosis, right scoliosis, and right scoliosis with thoracolumbar kyphosis. The aorta-vertebrae angle (α) and aorta-vertebrae distance (d) in each level of T12–L4 were measured by using a Cartesian coordinate system. t test of independent samples was performed, α and d were compared, and Pearson correlation analysis was employed for α, d, and X-ray radiographic measurements. Result The changes of α were not statistically significant (P > 0.05) in LS and LKS groups but d (P < 0.05) was longer in LKS group compared with the control group. In the right malformed group, there was no significant change in the angle (P > 0.05) in the abdominal aorta but longer d (P < 0.05) than the normal group. There was longer d in the RKS group compared with the RS group (P < 0.05). Pearson correlation analysis showed that there was a positive correlation between d and TLK (r = 0.439, P < 0.05). Conclusion In patients with ADS, a relative normal position is maintained between the aorta and vertebrae. While the aorta is slightly away from the left pedicle in RS patients and farther away in patients with kyphosis, the angle of kyphosis would become bigger and d becomes longer. Therefore, the surgeons should be aware of the changes of the aorta position to avoid the disastrous vessel injuries.
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Magnetic Resonance Imaging Study of Oblique Corridor and Trajectory to L1-L5 Intervertebral Disks in Lateral Position. World Neurosurg 2019; 134:e616-e623. [PMID: 31678316 DOI: 10.1016/j.wneu.2019.10.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study investigated the retroperitoneal oblique corridor and trajectory of L1-L5 as the lateral surgical access to the intervertebral disks in the Chinese population and detected the potential relationship between the corridor or trajectory and vertebral parameters, including disk axis, psoas muscle, and retroperitoneal vessel. METHODS Seventy magnetic resonance imaging studies performed from January 2017 to January 2019 were investigated. The oblique corridor was defined as the distance between the left lateral border of the retroperitoneal vessel and the anterior border of psoas. The trajectory was defined as the distance between the retroperitoneal vessel and lumbar plexus. RESULTS The oblique corridor analysis to L1-L5 disks have the following mean distances: L1-2 13.36 mm, L2-3 13.36 mm, L3-4 12.37 mm, and L4-5 10.36 mm. There was no difference in the L1-L5 corridor between genders. And the position of retroperitoneal vessel was negatively correlated with the corridor width. The trajectory measurements to L1-L5 disks have the following mean distances: L1-2 27.44 mm, L2-3 30.86 mm, L3-4 30.73 mm, and L4-5 24.36 mm. Moreover, the vertebral parameters, including the disk axis and psoas muscle, were positively correlated with the trajectory width. Otherwise, the position of retroperitoneal vessel was negatively correlated with the trajectory width. CONCLUSIONS Compared with previous studies, the safe surgical area of the Chinese is generally smaller than that of Caucasian. The position of the retroperitoneal vessel is the vital potential to limit the corridor and trajectory. Preoperative assessment of vertebral parameters, especially vascular structure, is essential for planning surgical process.
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Complications Associated With Minimally Invasive Anterior to the Psoas (ATP) Fusion of the Lumbosacral Spine. Spine (Phila Pa 1976) 2019; 44:E1122-E1129. [PMID: 31261275 DOI: 10.1097/brs.0000000000003071] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To analyze complications associated with minimally invasive anterolateral retroperitoneal antepsoas lumbosacral fusion (MIS-ATP). SUMMARY OF BACKGROUND DATA MIS-ATP provides anterolateral access to the lumbar spine allowing for safe anterior lumbar interbody fusions between T12-S1. Anecdotally, many surgeons believe that ATP approach is not feasible at L5-S1 level, predisposing to catastrophic vascular injuries. This approach may help overcome limitations associated with conventional straight anterior lumbar interbody fusions, MIS lateral lumbar interbody fusion, and oblique lateral interbody fusion. METHODS A detailed retrospective chart review of patients who had underwent MIS-ATP approach for lumbar fusion between T12-S1 was performed. Available electronic data from surgeries performed between January 2008 and March 2017 was carefully screened for surgical patients treated for spondylolisthesis, spondylosis, stenosis, sagittal, and/or coronal deformity. Detailed review of electronic medical records including operative notes, progress notes, discharge summaries, laboratory results, imaging reports, and clinic visit notes performed by a single independent reviewer not involved in patient care for documented complications. A complication is defined as any adverse event related to the index spine procedure for which patient required specific intervention or treatment. RESULTS Nine hundred forty patients with a total of 2429 interbody fusion levels performed via MIS-ATP were identified during the study period. Sixty-seven patients (7.2%) sustained one or more complications during the perioperative period, of which 25.5% were surgical and 74.5% were medical. Overall, 78 (8.2%) surgical complications pertaining to the index procedure were noted during a postoperative period of 1 year from the date of surgery. No major vascular or direct visceral injuries were encountered. CONCLUSIONS MIS-ATP approach provides a safe access to anterolateral interbody fusions between T12-S1. The ATP approach is performed by the spine surgeon, does not require neuromonitoring, and warrants minimal to no psoas muscle retraction resulting in significantly reduced postoperative thigh pain and rare neurologic injuries. Additionally, the direct and clear visualization of the retroperitoneal vasculature provided by the ATP approach minimizes the risk of inadvertent vascular injury. LEVEL OF EVIDENCE 4.
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Rustagi T, Yilmaz E, Alonso F, Schmidt C, Oskouian R, Tubbs RS, Chapman JR, Hopkins S, Schildhauer TA, Fisahn C. Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases. Global Spine J 2019; 9:375-382. [PMID: 31218194 PMCID: PMC6562219 DOI: 10.1177/2192568218800045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication. METHODS All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes. RESULTS A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days). CONCLUSIONS We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.
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Affiliation(s)
- Tarush Rustagi
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA,Indian Spinal Injuries Centre, New Delhi, India,Seattle Science Foundation, Seattle, WA, USA
| | - Emre Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA,Seattle Science Foundation, Seattle, WA, USA,BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany,Emre Yilmaz, Swedish Neuroscience Institute, Swedish
Medical Center, 550 17th Avenue, Suite 500 James Tower, 5th Floor, Seattle, WA 98122, USA.
| | - Fernando Alonso
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | - Cameron Schmidt
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA,Seattle Science Foundation, Seattle, WA, USA
| | - Rod Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA,Seattle Science Foundation, Seattle, WA, USA
| | - R. Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA,St George’s University, St George’s, Grenada
| | - Jens R. Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | - Sarah Hopkins
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | | | - Christian Fisahn
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA,Seattle Science Foundation, Seattle, WA, USA,BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany
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Xu S, Liang Y, Zhu Z, Wang K, Liu H. Position of the Aorta Relative to Vertebrae in Patients with Degenerative Thoracolumbar or Lumbar Scoliosis: A Case-Control Study. World Neurosurg 2019; 127:e1-e7. [PMID: 30851468 DOI: 10.1016/j.wneu.2019.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate the position of the aorta relative to the spine in patients with de novo lumbar scoliosis (DLS). METHODS This study enrolled 142 patients with DLS, including 80 cases of left thoracolumbar/lumbar scoliosis (left group) and 62 cases of right scoliosis (right group). In addition, 132 cases free of deformity were allocated to the control group. Parameters of the Cobb angle and apical vertebrae were measured by radiograph, whereas the left pedicle-vertebrae angle (α), rotation angle (γ), and left pedicle-vertebrae distance (d) of T12-L4 were obtained by magnetic resonance imaging. Independent sample t test was performed to compare α, γ, and d between the DLS and control groups, followed by a Pearson correlation analysis to study the correlation between Cobb angle and α, γ, and d. RESULTS No difference was found between the right group and control group (P = 0.554). The value of mean d (4.62 ± 0.57 cm) gradually increased from T12 to L4 in the left group and showed significant difference with the corresponding value in the control group (4.44 ± 0.43 cm; P < 0.001). There was no significant difference between the right group and control group (P = 0.762). The value of mean d (4.54 ± 1.84 cm) showed no significant difference between the right group and control group (P = 0.530). The correlation analysis showed a significant correlation between rotation angle γ and Cobb angle (P < 0.001), but not in α and d with Cobb angle. CONCLUSIONS Although the position of the aorta relative to the spine showed no significant difference between patients with DLS and normal subjects, great attention should still be paid to prevent DLS-induced aorta injury.
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Affiliation(s)
- Shuai Xu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing, P.R. China
| | - Yan Liang
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing, P.R. China
| | - Zhenqi Zhu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing, P.R. China
| | - Kaifeng Wang
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing, P.R. China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing, P.R. China.
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Bouyer B, Rudnichi A, Dray-Spira R, Zureik M, Coste J. Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients. J Thromb Haemost 2018; 16:1537-1545. [PMID: 29893460 DOI: 10.1111/jth.14205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Indexed: 01/24/2023]
Abstract
Essentials The risk of venous thromboembolism (VTE) after lumbar spine surgery (LBS) is not precisely known. More than 320 000 patients who underwent LBS in France between 2009 and 2014 were followed-up. The overall risk of VTE after LBS is less than 1% but modulated by patient and procedural factors. Surgical device implantation, anterior approach and complex surgery increase the risk of VTE. SUMMARY: Background Postoperative venous thromboembolism (VTE) is a severe complication, the risk of which after lumbar spine surgery (LBS) is not precisely known. Objective To estimate the incidence of VTE after LBS, and to identify individual and surgical risk factors. Methods All patients aged >18 years who underwent LBS in France between 2009 and 2014 were identified. Among 477 024 patients screened, exclusions concerned recent VTE or surgery, and multiple surgeries during the same hospital stay. Results In 323 737 patients (mean age 52.9 years, 51.4% male), we observed 2911 events (0.91%) after a median time of 12 days (Q1-Q3: 5-72 days). The multivariate adjusted Cox model showed increased risks associated with age (4% per year of age; 95% confidence interval [CI] 3.8-4.3), obesity (hazard ratio [HR] 1.32, 95% CI 1.18-1.46), active cancer (HR 1.65, 95% CI 1.5-1.82), previous thromboembolism (HR 5.41, 95% CI 4.74-6.17), severe paralysis (HR 1.47, 95% CI 1.17-1.84), renal disease (HR 1.28, 95% CI 1.04-1.6), psychiatric disease (HR 1.21, 95% CI 1.1-1.32), use of antidepressants (HR 1.13, 95% CI 1.03-1.24), use of contraceptives (HR 1.56, 95% CI 1.19-2.03), extended surgery for scoliosis (HR 3.61, 95% CI 2.96-4.4), implantation of pedicular screws with a 'dose-effect' association, and an anterior approach (HR 1.97, 95% CI 1.6-2.43) or a combined approach (HR 2.03, 95% CI 1.44-2.84). Conclusions The overall VTE risk after LBS is moderate (< 1%) but is widely modulated by several easily identifiable risk factors. The surgical community should be aware of this heterogeneity, adapt prevention according to patients and to the procedure, and use drug prophylaxis in the event of a high risk being present.
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Affiliation(s)
- B Bouyer
- French National Agency for Medicines and Health Products Safety, Saint Denis, France
- AP-HP and Paris-Descartes University, Paris, France
- Paris-Sud University, Paris, France
| | - A Rudnichi
- French National Agency for Medicines and Health Products Safety, Saint Denis, France
| | - R Dray-Spira
- French National Agency for Medicines and Health Products Safety, Saint Denis, France
| | - M Zureik
- French National Agency for Medicines and Health Products Safety, Saint Denis, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
| | - J Coste
- AP-HP and Paris-Descartes University, Paris, France
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Liang Y, Zhao Y, Liu H, Wang Z. The position of the aorta relative to the spine in patients with Pott's thoracolumbar angular kyphosis. J Orthop Sci 2018; 23:289-293. [PMID: 29198597 DOI: 10.1016/j.jos.2017.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/26/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
Abstract
STUDY DESIGN Analyze the position of the aorta in patients with Pott's thoracolumbar angular kyphosis by computed tomography. OBJECTIVE To investigate the anatomic position of the aorta relative to spine in patients with Pott's thoracolumbar angular kyphosis. SUMMARY OF BACKGROUND DATA The complication of aorta injury is rare in the procedure of spinal osteotomy for the correction of Pott's thoracolumbar angular kyphotic deformity. However, there would be a disastrous consequence once it happened. Therefore, knowing about the position of aorta relative to the spine is of great importance. From the authors' knowledge, there are no reports about the research on the position of the aorta relative to the spine in patients with Pott's thoracolumbar angular kyphosis. METHODS Thirty patients with Pott's thoracolumbar angular kyphosis and thirty patients without spine deformity were recruited and divided into two groups. The CT images of both groups from T10 to L1 were obtained to evaluate the left pedicle-aorta angle and distance. In the patients with Pott's thoracolumbar angular kyphosis, the affected vertebral bodies were fused, so we measured the left pedicle-aorta angle and distance of the fused vertebral bodies. For the normal group, we measured the left pedicle-aorta angle and distance from T10 to L1 and got the average data, then compared with the Pott's group with independent sample t test. The Pearson correlation analysis was used to evaluate the association between the change of the aortic position and Konstam's angle and LL. RESULTS The left pedicle-aorta angles (-8.95 + 2.89°) in Pott's group are smaller and the distances (6.36 + 0.77 cm) are larger than those in normal group (P < 0.05). In patients with Pott's thoracolumbar angular kyphosis, with increased Konstam's angle, the left pedicle-aorta angles becomes smaller (r = -0.495, P < 0.05) and the left pedicle-aorta distances becomes larger (r = 0.486, P < 0.05). However, there is no remarkable correlation between lumbar lordosis and the left pedicle-aorta angles or distances. CONCLUSION In patients with Pott's thoracolumbar angular kyphosis, the aorta of the fused vertebrate shifts anteromedially to the vertebral body, and the aorta is relatively farther away from the vertebral body compared with the normal subjects. Therefore, the surgeon should be aware of the change of the position of the aorta to avoid the disastrous complication vessel injury.
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Affiliation(s)
- Yan Liang
- Peking University People's Hospital, Beijing, 100044, China.
| | - Yongfei Zhao
- The General Hospital of Chinese People's Liberation Army (301 Hospital), Beijing, 100853, China.
| | - Haiying Liu
- Peking University People's Hospital, Beijing, 100044, China.
| | - Zheng Wang
- The General Hospital of Chinese People's Liberation Army (301 Hospital), Beijing, 100853, China.
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Evaluation of Two Novel Integrated Stand-Alone Spacer Designs Compared with Anterior and Anterior-Posterior Single-Level Lumbar Fusion Techniques: An In Vitro Biomechanical Investigation. Asian Spine J 2017; 11:854-862. [PMID: 29279739 PMCID: PMC5738305 DOI: 10.4184/asj.2017.11.6.854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/28/2017] [Accepted: 03/20/2017] [Indexed: 12/03/2022] Open
Abstract
Study Design In vitro biomechanical investigation. Purpose To compare the biomechanics of integrated three-screw and four-screw anterior interbody spacer devices and traditional techniques for treatment of degenerative disc disease. Overview of Literature Biomechanical literature describes investigations of operative techniques and integrated devices with four dual-stacked, diverging interbody screws; four alternating, converging screws through a polyether-ether-ketone (PEEK) spacer; and four converging screws threaded within the PEEK spacer. Conflicting reports on the stability of stand-alone devices and the influence of device design on biomechanics warrant investigation. Methods Fourteen cadaveric lumbar spines were divided randomly into two equal groups (n=7). Each spine was tested intact, after discectomy (injured), and with PEEK interbody spacer alone (S), anterior lumbar plate and spacer (AP+S), bilateral pedicle screws and spacer (BPS+S), circumferential fixation with spacer and anterior lumbar plate supplemented with BPS, and three-screw (SA3s) or four-screw (SA4s) integrated spacers. Constructs were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Researchers performed one-way analysis of variance and independent t-testing (p≤0.05). Results Instrumented constructs showed significantly decreased motion compared with intact except the spacer-alone construct in FE and AR (p≤0.05). SA3s showed significantly decreased range of motion (ROM) compared with AP+S in LB (p≤0.05) and comparable ROM in FE and AR. The three-screw design increased stability in FE and LB with no significant differences between integrated spacers or between integrated spacers and BPS+S in all loading modes. Conclusions Integrated spacers provided fixation statistically equivalent to traditional techniques. Comparison of three-screw and four-screw integrated anterior lumbar interbody fusion spacers revealed no significant differences, but the longer, larger-diameter interbody spacer with three-screw design increased stabilization in FE and LB; the diverging four-screw design showed marginal improvement during AR.
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Cao Y, Liu F, Wan S, Liang Y, Jiang C, Feng Z, Jiang X, Chen Z. Biomechanical evaluation of different surgical procedures in single-level transforaminal lumbar interbody fusion in vitro. Clin Biomech (Bristol, Avon) 2017; 49:91-95. [PMID: 28898815 DOI: 10.1016/j.clinbiomech.2017.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS A variety of improved surgical methods were adopted in the transforaminal lumbar interbody fusion. A mechanical stability provides an ideal environment for the formation of a fusion mass and is the basis of their good outcomes. The object of this study is to evaluate the initial similarities and differences of four commonly-used posterior surgical procedures biomechanically. METHODS Biomechanical testing was performed at L3-4 motion segment in 6 fresh-frozen human cadaveric lumbar spines (L2-L5), including the following sequentially tested configurations: 1) intact motion segment; 2) bilateral pedicle screw fixation; 3) unilateral pedicle screw fixation; 4) unilateral pedicle screw plus contralateral translaminar facet joint screw fixation according to the Magerl technique; and 5) bilateral pedicle screw fixation with bilateral facetectomies. The range of motion, neutral zone and stiffness of each method and intact segment were collected and compared. FINDINGS All of four methods reduce the range of motion significantly in flexion and extension and lateral bending but not in axial torsion compared with the native segment. There is no significant difference among four procedures about the range of motion in all loading modes. All of methods increase the stiffness of segmental motion compared with intact segment in all loading modes, but only bilateral pedicle screw fixation showed significant increases in stiffness in flexion and extension(p=0.02) and lateral bending(p=0.023). The stiffness offered by instrumented constructs in different methods showed no significant difference in all loading modes. INTERPRETATION The stiffness offered by four different posterior fixations in single segmental transforaminal lumbar interbody fusion is not significantly different.
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Affiliation(s)
- Yuanwu Cao
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fubing Liu
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengcheng Wan
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Liang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenzhou Feng
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoxing Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zixian Chen
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
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Zhang QH, Guo Q, Guo C, Wu J, Liu J, Gao Q, Wang Y. A medium-term follow-up of adult lumbar tuberculosis treating with 3 surgical approaches. Medicine (Baltimore) 2017; 96:e8574. [PMID: 29137080 PMCID: PMC5690773 DOI: 10.1097/md.0000000000008574] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Surgical intervention is an important option for treating lumbar tuberculosis. Previous studies have reported different surgical intervention procedures. To our knowledge, few studies have compared the clinical results of mid-term follow-up of 3 different surgeries in surgical treatment of spinal tuberculosis. This study's purpose is to evaluate the effectiveness of 3 different surgeries for the treatment of lumbar tuberculosis in adult and analyze the mid-term influence of the surgery on quality of life.Between June 2004 and January 2010, a total of 137 adult patients (54 women and 83 men) with lumbar tuberculosis were recruited for this study. The patients were divided into 3 groups based on administered surgeries: posterior, anterior, and combined posterior-anterior. The trauma index (operation time, blood loss, length of hospital stay, and complications), imaging parameters (segment kyphotic angle, correction rate, loss angle, and bone fusion time), and quality-of-life indicators, including Oswestry Disability Index (ODI), the Frankel grade, visual analog scale (VAS), and Macnab score, were collected.The posterior group experienced the lowest trauma index, whereas the combined group faced the highest trauma index. The anterior group's kyphosis correction rate of (52% ± 5.45%) was significantly inferior to the posterior group (74% ± 5.04%) and the combined group (69% ± 7.95%), whereas the loss of correction in the anterior group (2.5°) was higher than the losses of correction in the posterior group (0.8°) and combined group (1.1°). The mean bone fusion times of the 3 groups were similar. Postsurgery quality of life was markedly improved in all patients. The improvement rates of the ODI, VAS, and the excellent and good rate per the Macnab score were similar among the 3 groups at the final follow-up.Based on a retrospective study, for patients with lumbar tuberculosis, use of the anterior approach should be limited. Although the combined approach produced satisfactory outcomes, it remains more traumatic. Compared with the anterior surgery and the combined surgery, the posterior-only approach is safer and less invasive.
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Hsieh CS, Lee HC, Oh HS, Park SJ, Hwang BW, Lee SH. Anterior lumbar interbody fusion with percutaneous pedicle screw fixation for multiple-level isthmic spondylolisthesis. Clin Neurol Neurosurg 2017; 158:49-52. [PMID: 28460342 DOI: 10.1016/j.clineuro.2017.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/11/2017] [Accepted: 04/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Multiple-level lumbar isthmic spondylolisthesis is rarely reported. Here, we report 23 consecutive patients who underwent anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) for multiple-level isthmic spondylolisthesis. PATIENTS AND METHODS From June 2008 through December 2014, multiple-level lumbar isthmic spondylolisthesis was diagnosed in 23 patients (6 men, 17 women) at Wooridul Spine Hospital (Busan, South Korea). Isthmic spondylolisthesis occurred at three spinal levels in 2 patients and at two levels in 21 patients. All patients underwent ALIF with PPF. We used the Oswestry Disability Index (ODI) and visual analog scale scores to evaluate the preoperative and postoperative functional outcome, low back pain, and radicular pain. We also evaluated segmental lordosis and the fusion status using radiographs and data from computed tomography. RESULTS Isthmic spondylolisthesis occurred from L3 to S1 and mostly occurred at two consecutive spinal levels (i.e., L4-L5 and L5-S1). Significant improvements in the ODI and visual analog scale were observed in patients at final follow up (p<0.05). The mean segmental lordosis significantly increased after operation (from 22.7° to 32.7°). The mean lumbar lordosis significantly increased after operation (from 45.8 to 53.1). Radiographs of all of the patients showed solid fusion at the last follow-up. There was one case of screw fracture at the S1 level; however, in this case the last follow-up radiograph exhibited solid fusion. CONCLUSIONS Anterior lumbar interbody fusion with PPF can be an effective treatment choice and yield good clinical outcomes in patients with multiple-level isthmic spondylolisthesis.
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Affiliation(s)
- Chang-Sheng Hsieh
- Department of Orthopedics, Wooridul Spine Hospital, Busan, Republic of Korea
| | - Hyung Chang Lee
- Department of Cardiovascular Surgery, Wooridul Spine Hospital, Busan, Republic of Korea.
| | - Hyeong-Seok Oh
- Department of Neurosurgery, Wooridul Spine Hospital, Busan, Republic of Korea
| | - Sang-Joon Park
- Department of Neurosurgery, Wooridul Spine Hospital, Busan, Republic of Korea
| | - Byeong-Wook Hwang
- Department of Neurosurgery, Wooridul Spine Hospital, Busan, Republic of Korea
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Republic of Korea
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ALIF- und PLIF-Interposition bei low-grade isthmischen Spondylolisthesen L5/S1. DER ORTHOPADE 2016; 45:760-9. [DOI: 10.1007/s00132-016-3311-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abt NB, De la Garza-Ramos R, Olorundare IO, McCutcheon BA, Bydon A, Fogelson J, Nassr A, Bydon M. Thirty day postoperative outcomes following anterior lumbar interbody fusion using the national surgical quality improvement program database. Clin Neurol Neurosurg 2016; 143:126-31. [PMID: 26937864 DOI: 10.1016/j.clineuro.2016.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 11/25/2022]
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Comparison of clinical efficacy and safety among three surgical approaches for the treatment of spinal tuberculosis: a meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3862-3874. [DOI: 10.1007/s00586-016-4546-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 03/22/2016] [Accepted: 03/22/2016] [Indexed: 01/27/2023]
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Effect of Anatomic Variability and Level of Approach on Perioperative Vascular Complications With Anterior Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2016; 41:E73-7. [PMID: 26335679 DOI: 10.1097/brs.0000000000001160] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE The study aim was to determine the prevalence of vascular complications associated with anterior lumbar interbody fusion (ALIF) as a function of anatomic variation and the number of levels fused. SUMMARY OF BACKGROUND DATA ALIF often requires mobilization of the great vessels, particularly when exposing levels above L5-S1. The exposure can be more challenging in the setting of spondylolisthesis or transitional anatomy. METHODS This retrospective review of prospectively collected data from our spine database identified 204 patients who had undergone single level (n = 142) or multilevel (n = 62) ALIF from 2008 to 2013 with minimum 6-month follow-up. Average age was 58 years; 57% were female. Preoperative radiographic assessment for spondylolisthesis and transitional anatomy was performed. Body mass index, estimated blood loss, and levels of ALIF were recorded. Intraoperative vascular injury, postoperative deep venous thrombosis, and pulmonary embolism events were noted. RESULTS Eleven patients experienced postoperative thromboembolic events and were more likely to have had intraoperative vascular injury compared with patients who did not develop a vascular complication (36% and 5%, respectively; P = 0.004). Estimated blood loss was significantly higher in patients with spondylolisthesis when compared to patients without spondylolisthesis (520 cc vs. 103 cc, respectively; P = 0.017) or transitional anatomy (347 cc vs. 262 cc, respectively; P = 0.022). Patients undergoing multilevel ALIF had significantly higher blood loss than patients undergoing a single level procedure (684 cc vs. 107 cc; P < 0.001). Patient characteristics, blood loss, anatomic variation, and level of approach were not associated with the development of postoperative thromboembolic complications. CONCLUSION Performing ALIF in the setting of spondylolisthesis or transitional anatomy resulted in higher blood loss. Patients undergoing multilevel rather than single level ALIF experienced greater blood loss. Because patients with intraoperative vascular injury had increased likelihood of postoperative thromboembolic event, thrombosis prophylaxis should be considered in these patients. LEVEL OF EVIDENCE 4.
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Lara-Almunia M, Gomez-Moreta JA, Hernandez-Vicente J. Posterior lumbar interbody fusion with instrumented posterolateral fusion in adult spondylolisthesis: description and association of clinico-surgical variables with prognosis in a series of 36 cases. Int J Spine Surg 2015. [PMID: 26196029 DOI: 10.14444/2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We present our experience in the treatment of patients with isthmic or degenerative spondylolisthesis, by means of a posterior lumbar interbody fusion (PLIF) and instrumented posterolateral fusion (IPLF), and we compare them with those published in the literature. We analyse whether there exists any statistical association between the clinical characteristics of the patient, radiological characteristics of the disease and our surgical technique, with the complications and the clinical-radiological prognosis of the cases. METHOD We designed a prospective study. A total of 36 cases were operated. The patients included were 14 men and 22 women, with an average age of 57.17±27.32 years. Our technique consists of PLIF+IPLF, using local bone for the fusion. The clinical results were evaluated with the Visual Analogical Scale (VAS) and the Kirkaldy-Willis criteria. The radiological evaluation followed the Bratingan (PLIF) and Lenke (IPLF) methodology. A total of 42 variables were statistically analysed by means of SPSS18. We used the Paired Student's T-test, logistic regression and Pearson's Chi-square-test. RESULTS The spondylolisthesis was isthmic in 15 cases and degenerative in 21 cases. The postoperative evaluations had excellent or good results in 94.5% (n = 34), with a statistically significant improvement in the back pain and sciatica (p < 0.01). The rate of circumferential fusion reached was approximately 92%. We had 13.88% of transitory morbility and 0% of mortality associated with our technique. A greater age, degree of listhesis or length of illness before the intervention, weakly correlated with worse clinical results (p< -0.2). In our series, the logistical regression showed that the clinical characteristics of the patient, radiological characteristics of the lesion and our surgical technique were not associated with greater postoperative complications. CONCLUSION Although a higher level of training is necessary, we believe that the described technique is a very effective decision in cases of spondylolisthesis, isthmic or degenerative, refractory to conservative treatment, for the obtaining the best clinical results and rates of fusion, with similar risks to those of the other published techniques. Our statistical analysis could contribute to improve outcomes after surgery.
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Affiliation(s)
- Monica Lara-Almunia
- Department of Neurosurgery, Son Espases University Hospital, Mallorca, Spain
| | - Juan A Gomez-Moreta
- Department of Neurosurgery, University Hospital of Salamanca, Salamanca, Spain
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Sim EM, Claydon MH, Parker RM, Malham GM. Brief intraoperative heparinization and blood loss in anterior lumbar spine surgery. J Neurosurg Spine 2015; 23:309-13. [PMID: 26047346 DOI: 10.3171/2014.12.spine14888] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The anterior approach to the lumbar spine may be associated with iliac artery thrombosis. Intraoperative heparin can be administered to prevent thrombosis; however, there is a concern that this will increase the procedural blood loss. The aim of this study was to examine whether intraoperative heparin can be administered without increasing blood loss in anterior lumbar spine surgery. METHODS A prospective study of consecutive anterior approaches for lumbar spine surgery was performed between January 2009 and June 2014 by a single vascular surgeon and a single spine surgeon. Patients underwent an anterior lumbar interbody fusion (ALIF) at L4-5 and/or L5-S1, a total disc replacement (TDR) at L4-5 and/or L5-S1, or a hybrid procedure with a TDR at L4-5 and an ALIF at L5-S1. Heparin was administered intravenously when arterial flow to the lower limbs was interrupted during the procedure. Heparin was usually reversed on removal of the causative retraction. RESULTS The cohort consisted of 188 patients with a mean age of 41.7 years; 96 (51.1%) were male. Eighty-four patients (44.7%) had an ALIF, 57 (30.3%) had a TDR, and 47 (25.0%) had a hybrid operation with a TDR at L4-5 and an ALIF at L5-S1. One hundred thirty-four patients (71.3%) underwent a single-level procedure (26.9% L4-5 and 73.1% L5-S1) and 54 (28.7%) underwent a 2-level procedure (L4-5 and L5-S1). Seventy-two patients (38.3%) received heparinization intraoperatively. Heparin was predominantly administered during hybrid operations (68.1%), 2-level procedures (70.4%), and procedures involving the L4-5 level (80.6%). There were no intraoperative ischemic vascular complications reported in this series. There was 1 postoperative deep venous thrombosis. The overall mean estimated blood loss (EBL) for the heparin group (389.7 ml) was significantly higher than for the nonheparin group (160.5 ml) (p < 0.0001). However, when all variables were analyzed with multiple linear regression, only the prosthesis used and level treated were found to be significant in blood loss (p < 0.05). The highest blood loss occurred in hybrid procedures (448.1 ml), followed by TDR (302.5 ml) and ALIF (99.7 ml). There were statistically significant differences between the EBL during ALIF compared with TDR and hybrid (p < 0.0001), but not between TDR and hybrid. The L4-5 level was associated with significantly higher blood loss (384.9 ml) compared with L5-S1 (111.4 ml) (p < 0.0001). CONCLUSIONS During an anterior exposure for lumbar spine surgery, the administration of heparin does not significantly increase blood loss. The prosthesis used and level treated were found to significantly increase blood loss, with TDR and the L4-5 level having greater blood loss compared with ALIF and L5-S1, respectively. Heparin can be administered safely to help prevent thrombotic intraoperative vascular complications without increasing blood loss.
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Uribe JS, Deukmedjian AR. Visceral, vascular, and wound complications following over 13,000 lateral interbody fusions: a survey study and literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24 Suppl 3:386-96. [DOI: 10.1007/s00586-015-3806-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/08/2015] [Accepted: 02/08/2015] [Indexed: 11/29/2022]
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Huang ZY, Ding ZQ, Liu HY, Fang J, Liu H, Sha M. Anterior D-rod and titanium mesh fixation for acute mid-lumbar burst fracture with incomplete neurologic deficits: A prospective study of 56 consecutive patients. Indian J Orthop 2015; 49:471-7. [PMID: 26229171 PMCID: PMC4510804 DOI: 10.4103/0019-5413.159680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anterior decompression and reconstruction have gained wide acceptance as viable alternatives for unstable mid-lumbar burst fracture, but there are no mid and long term prospective studies regarding clinical and radiologic results of mid-lumbar burst fractures. MATERIALS AND METHODS An Institutional Review Board-approved prospective study of 56 consecutive patients of mid-lumbar burst fractures with a load-sharing score of 7 or more treated with anterior plating was carried out. All patients were evaluated for radiologic and clinical outcomes. The fusion status, spinal canal compromise, segmental kyphotic angle (SKA), vertebral body height loss (VBHL), and adjacent segment degeneration was examined for radiologic outcome, whereas the American Spinal Injury Association scale, the visual analog scale (VAS), and the employment status were used for clinical evaluation. RESULTS The patients underwent clinical and radiologic followup for at least 5 years after the surgery. At the last followup, there was no case of internal fixation failure, adjacent segment degeneration, and other complications. Interbody fusion was achieved in all cases. The average fusion time was 4.5 months. No patient suffered neurological deterioration and the average neurologic recovery was 1.3 grades on final observation. Based on VAS pain scores, canal compromise, percentage of VBHL and SKA, the difference was statistically significant between the preoperative period and postoperative or final followup (P < 0.05). Results at postoperative and final followup were better than the preoperative period. However, the difference was not significant between postoperative and final followup (P > 0.05). Thirty-four patients who were employed before the injury returned to work after the operation, 15 had changed to less strenuous work. CONCLUSION Good mid term clinicoradiological results of anterior decompression with D-rod and titanium mesh fixation for suitable patients with mid-lumbar burst fractures with incomplete neurologic deficits can be achieved. The incident rate of complications was low. D-rod is a reliable implant and has some potential advantages in L4 vertebral fractures.
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Affiliation(s)
- Zhe-yuan Huang
- Department of Orthopaedics, The 174th Hospital of PLA, Spinal Orthopaedics Center of PLA, Chenggong Hospital of Xiamen University, Xiamen Fujian Province, China
| | - Zhen-qi Ding
- Department of Orthopaedics, The 175th Hospital of PLA, Traumatic Orthopaedics Center of PLA, Southeast Hospital of Xiamen University, Zhangzhou Fujian Province, China,Address for correspondence: Dr. Zhen-qi Ding, Department of Orthopaedics, The 175th Hospital of PLA, Traumatic Orthopaedics Center of PLA, Southeast Hospital of Xiamen University, Zhangzhou Fujian Province, 363000, China. E-mail:
| | - Hao-yuan Liu
- Department of Orthopaedics, The 174th Hospital of PLA, Spinal Orthopaedics Center of PLA, Chenggong Hospital of Xiamen University, Xiamen Fujian Province, China
| | - Jun Fang
- Department of Orthopaedics, The 180th Hospital of PLA, Spinal Orthopaedics Center of PLA, Quanzhou Fujian Province, China
| | - Hui Liu
- Department of Orthopaedics, The 175th Hospital of PLA, Traumatic Orthopaedics Center of PLA, Southeast Hospital of Xiamen University, Zhangzhou Fujian Province, China
| | - Mo Sha
- Department of Orthopaedics, The 175th Hospital of PLA, Traumatic Orthopaedics Center of PLA, Southeast Hospital of Xiamen University, Zhangzhou Fujian Province, China
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Richter M, Weidenfeld M, Uckmann F. Die ventrale lumbale interkorporelle Fusion. DER ORTHOPADE 2014; 44:154-61. [DOI: 10.1007/s00132-014-3056-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sethi RK, Pong RP, Leveque JC, Dean TC, Olivar SJ, Rupp SM. The Seattle Spine Team Approach to Adult Deformity Surgery: A Systems-Based Approach to Perioperative Care and Subsequent Reduction in Perioperative Complication Rates. Spine Deform 2014; 2:95-103. [PMID: 27927385 DOI: 10.1016/j.jspd.2013.12.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 12/04/2013] [Accepted: 12/08/2013] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective consecutive case review pre- and postintervention. OBJECTIVES Characterize the effects of the intervention. SUMMARY OF BACKGROUND DATA Complication rates in adult spinal deformity surgery are unacceptable. System approaches are necessary to increase patient safety. This group reported on the dual-attending surgeon approach, a live multidisciplinary preoperative screening conference, and the intraoperative protocol for the management of coagulopathy. The outcomes were demonstrated by complication rates before and after the institution of this protocol. METHODS Forty consecutive patients in Group A were managed without the 3-pronged approach. A total of 124 consecutive patients in Group B had a dual-attending surgeon approach, were presented and cleared by a live multidisciplinary preoperative conference, and were managed according to the intraoperative protocol. RESULTS Group A had an average age of 62 years (range, 39-84 years). Group B had an average age of 64 years (range, 18-84 years). Most patients in both groups had fusions from 9 to 15 levels. Complication rates in Group B were significantly lower (16% vs. 52%) (p < .001). Group B showed significantly lower return rates to the operating room during the perioperative 90-day period (0.8% vs. 12.5%) (p < .001). Group B also had lower rates of wound infection requiring debridement (1.6% vs. 7.5%), lower rates of deep vein thrombosis/pulmonary embolism (3.2% vs. 10%), and lower rates of postoperative neurological complications (0.5% vs. 2.5%) (not significant). Group B had significantly lower rates of urinary tract infection requiring antibiotics (9.7% vs. 32.5%) (p < .001). CONCLUSIONS These data suggests that a team approach consisting of a dual-attending surgeon approach in the operating room, a live preoperative screening conference, and an intraoperative protocol for managing coagulopathy will significantly reduce perioperative complication rates and enhance patient safety in patients undergoing complex spinal reconstructions for adult spinal deformity.
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Affiliation(s)
- Rajiv K Sethi
- Department of Neurosurgery, Group Health Physicians and Virginia Mason Medical Center, Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Ryan P Pong
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jean-Christophe Leveque
- Department of Neurosurgery, Group Health Physicians and Virginia Mason Medical Center, Seattle, WA, USA
| | - Thomas C Dean
- Department of Anesthesia, Group Health Physicians, Seattle, WA, USA
| | - Stephen J Olivar
- Department of Anesthesia, Group Health Physicians, Seattle, WA, USA
| | - Stephen M Rupp
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, WA, USA
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Liu L, Wang H, Zhou Q, Guo D, Lan Y, Liu L. Large blood vessel stretch in lumbar spine through anterior surgical approach: An experimental study in adult goat. Indian J Orthop 2014; 48:178-83. [PMID: 24741140 PMCID: PMC3977374 DOI: 10.4103/0019-5413.128762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Various anterior lumbar surgical approaches, including the minimally invasive approach, have greatly improved in recent years. Vascular complications resulting from ALIF are frequently reported. Little information is available about the safety of large blood vessel stretch. We evaluated the right side stretch limit (RSSL) of the abdominal aorta (AAA) and the inferior vena cava (IVC) without blood flow occlusion and investigated stretch-induced histological injury and thrombosis in the iliac and femoral arteries and veins and the stretched vessels. MATERIALS AND METHODS The RSSL of blood vessels in five adult goats was measured by counting the number of 0.5-cm-thick wood slabs that were inserted between the right lumbar edge and the stretch hook. Twenty seven adult goats were divided into three groups to investigate histological injury and thrombosis under a stretch to 0.5 cm (group I) 1.5 cm (group II) for 2 h, or no stretch (group III). Blood vessel samples from groups I and II were analyzed on postsurgical days 1, 3, and 7. Thrombogenesis was examined in the iliac and femoral arteries and veins. RESULTS The RSSL of large blood vessels in front of L4/5 was 1.5 cm from the right lumbar edge. All goats survived surgery without complications. No injury or thrombosis in the large blood vessels in front of the lumbar vertebrae and in the iliac or femoral arteries and veins was observed. Under light microscopy, group I showed slight swelling of endothelial cells in the AAA and no histological injury of the IVC. The AAA of group II showed endothelial cell damage, unclear organelles, and incomplete cell connections by electron microscopy. CONCLUSIONS The AAA and IVC in a goat model can be stretched by ≤0.5 cm, with no thrombosis in the AAA, IVC, iliac or femoral arteries and veins.
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Affiliation(s)
- Liehua Liu
- Department of Orthopedics, Orthopedics Center of PLA, Chongqing, China
| | - Haoming Wang
- Department of Orthopedics, Orthopedics Center of PLA, Chongqing, China
| | - Qiang Zhou
- Department of Orthopedics, Orthopedics Center of PLA, Chongqing, China,Address for correspondence: Prof. Qiang Zhou, Department of Orthopedics, Orthopedics Center of PLA, Third Military Medical University, Chongqing 400038, China. E-mail:
| | - Deyu Guo
- Department of Pathology, Southwest Hospital, Chongqing, China
| | - Yangjun Lan
- Department of Surgically Applied Anatomy and Surgery, Third Military Medical University, Chongqing, China
| | - Ling Liu
- Department of Health Statistics, Third Military Medical University, Chongqing, China
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König MA, Ebrahimi FV, Nitulescu A, Behrbalk E, Boszczyk BM. Early results of stand-alone anterior lumbar interbody fusion in iatrogenic spondylolisthesis patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:2876-83. [PMID: 24043336 DOI: 10.1007/s00586-013-2970-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 07/01/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Iatrogenic spondylolisthesis is a challenging condition for spinal surgeons. Posterior surgery in these cases is complicated by poor anatomical landmarks, scar tissue adhesion of muscle and dural structures and difficult access to the intervertebral disc. Anterior interbody fusion provides an alternative treatment method, allowing indirect foraminal decompression, reliable disc clearance and implantation of large surface area implants. MATERIALS AND METHODS A retrospective chart review of patients with iatrogenic spondylolisthesis including pre- and post-operative Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores was performed. Imaging criteria were pelvic incidence, overall lumbar lordosis and segmental lordosis. In addition, the fusion rate was investigated after 6 months. RESULTS Six consecutive patients treated between 2008 and 2011 (4 female, 2 male, mean age 61 ± 7.1 years) were identified. The initially performed surgeries included decompression with or without discectomy; posterior instrumented and non-instrumented fusion. The olisthetic level was in all cases at the decompressed level. All patients were revised with stand-alone anterior interbody fusion devices at the olisthetic level filled with BMP 2. Average ODI dropped from 49 ± 11 % pre-operatively to 26.0 ± 4.0 at 24 months follow-up. VAS average dropped from 7 ± 1 to 2 ± 0. Mean total lordosis of 39.8 ± 2.8° increased to 48.5 ± 4.9° at pelvic incidences of 48.8 ± 6.8° pre-operatively. Mean segmental lordosis at L4/5 improved from 10.5 ± 6.7° to 19.0 ± 4.9° at 24 months. Mean segmental lordosis in L5/S1 increased from 15.1 ± 7.4° to 23.2 ± 5.6°. Cage subsidence due to severe osteoporosis occurred in one case after 5 months, and hence there was no further follow-up. Fusion was confirmed in all other patients. CONCLUSION Anterior interbody fusion offers good stabilisation and restoration of lordosis in iatrogenic spondylolisthesis and avoids the well-known problems associated with reentering the spinal canal for revision fusions. In this group, ODI and VAS scores were improved.
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Affiliation(s)
- M A König
- The Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK,
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Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis. Spine (Phila Pa 1976) 2013; 38:E755-62. [PMID: 23442780 DOI: 10.1097/brs.0b013e31828d6ca3] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospectively enrolled, retrospectively analyzed matched cohort analysis. OBJECTIVE Evaluate the relative merits of transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) when performed in long deformity constructs. SUMMARY OF BACKGROUND DATA Interbody fusion is frequently used at the caudal levels of long-segment spinal deformity instrumentation constructs to protect the sacral implants and enhance fusion rates. However, there is a paucity of literature regarding which technique is more efficacious. METHODS Forty-two patients who underwent TLIF and 42 patients who underwent ALIF were matched with respect to age, sex, comorbidities, curve magnitude, fusion length, and ALIF/TLIF level. Radiographs and clinical outcomes were compared at minimum 2-year follow-up. RESULTS Age averaged 54.0 years and instrumented vertebrae averaged 13.6. TLIFs had less operative time (481 vs. 595 min, P = 0.0007), but greater blood loss (2011 vs. 1281 mL, P = 0.0002). Overall complications (TLIF, 12/42 vs. ALIF, 15/42) and neurological complications (TLIF, 4/42 vs. ALIF, 3/42) did not differ. One pseudarthrosis occurred at an ALIF level, with none at TLIF levels. Patients who underwent ALIF began with lower SRS scores but showed more improvement (44.4 to 70.7 vs. 58.6 to 70.6, P = 0.0043). ODI scores in both groups improved similarly. Regionally, ALIFs engendered more lordosis than TLIFs at L3-S1 (gain of 6.9° vs. -2.6°, P < 0.0001) but not T12-S1 (gain of 11.5° vs. 7.9°, P = 0.29). Locally, ALIFs created more lordosis at L4-L5 (gain of 5.6° vs. -1.7°, P < 0.0001) and L5-S1 (gain of 2.5° vs. -1.4°, P = 0.022), but not at L3-L4 (gain of 5.3° vs. 4.0°, P = 0.65). Patients who underwent TLIF obtained greater correction of anteroposterior Cobb angles in lumbar (reduction of 22.4° vs. 9.9°, P < 0.0001) and lumbosacral curves (reduction of 10.3° vs. 3.4°, P < 0.0001). CONCLUSION Spinal deformity surgery used TLIFs rather than ALIFs resulted in shorter operative time with no difference in complication rates. ALIFs provided more segmental lordosis, whereas TLIFs afforded better correction of scoliotic curves.
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Barrey C, Ene B, Louis-Tisserand G, Montagna P, Perrin G, Simon E. Vascular Anatomy in the Lumbar Spine Investigated by Three-Dimensional Computed Tomography Angiography: The Concept of Vascular Window. World Neurosurg 2013; 79:784-91. [DOI: 10.1016/j.wneu.2012.03.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 01/27/2012] [Accepted: 03/29/2012] [Indexed: 01/26/2023]
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Rodgers SD, Marascalchi BJ, Grobelny BT, Smith ML, Samadani U. Revision surgery after interbody fusion with rhBMP-2: a cautionary tale for spine surgeons. J Neurosurg Spine 2013; 18:582-7. [PMID: 23560709 DOI: 10.3171/2013.3.spine12377] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recombinant human bone morphogenetic protein-2 (rhBMP-2) promotes the induction of bone growth and is widely used in spine surgery to enhance arthrodesis. Recombinant human BMP-2 has been associated with a variety of complications including ectopic bone formation, adjacent-level fusion, local bone resorption, osteolysis, and radiculitis. Some of the complications associated with rhBMP-2 may be the result of rhBMP-2 induction of the inflammatory host response. In this paper the authors report on a patient with prior transforaminal lumbar interbody fusion (TLIF) using an interbody cage packed with rhBMP-2, in which rhBMP-2 possibly contributed to vascular injury during an attempted anterior lumbar interbody fusion. This 63-year-old man presented with a 1-year history of worsening refractory low-back pain and radiculopathy caused by a Grade 1 spondylolisthesis at L4-5. He underwent an uncomplicated L4-5 TLIF using an rhBMP-2-packed interbody cage. Postoperatively, he experienced marginal improvement of his symptoms. Within the next year and a half the patient returned with unremitting low-back pain and neurogenic claudication that failed to respond to conservative measures. Radiological imaging of the patient revealed screw loosening and pseudarthrosis. He underwent an anterior retroperitoneal approach with a plan for removal of the previous cage, complete discectomy, and placement of a femoral ring. During the retroperitoneal approach the iliac vein was adhered with scarring and fibrosis to the underlying previously operated L4-5 interbody space. During mobilization the left iliac vein was torn, resulting in significant blood loss and cardiac arrest requiring chest compression, defibrillator shocks, and blood transfusion. The patient was stabilized, the operation was terminated, and he was transferred to the intensive care unit. He recovered over the next several days and was discharged at his neurological baseline. The authors propose that the rhBMP-2-induced host inflammatory response partially contributed to vessel fibrosis and scarring, resulting in the life-threatening vascular injury during the reoperation. Spine surgeons should be aware of this potential inflammatory fibrosis in addition to other reported complications related to rhBMP-2.
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Affiliation(s)
- Shaun D Rodgers
- Department of Neurosurgery, NYU Medical Center, New York, New York, USA
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Somatosensory-evoked potential monitoring detects iliac artery occlusion during posterior spinal fusion. Spine (Phila Pa 1976) 2013; 38:E436-9. [PMID: 23324925 DOI: 10.1097/brs.0b013e318286f239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Report of a rare case of iliac artery occlusion occurring during posterior spinal surgery. OBJECTIVE To clarify causes of an acute occlusion of iliac vessels during posterior spinal surgery. SUMMARY OF BACKGROUND DATA Acute embolic occlusion of the iliac artery is a medical and surgical emergency. Iatrogenic occlusion of major vessels to the lower extremities during posterior lumbar spine operation is a rare entity. METHODS We report this complication occurring during decompression and fusion in a 55-year-old female with history of diabetes, hyperlipidemia, and multivessels vascular disease. The application of somatosensory evoked potentials during this case detected an asymmetry of cortical responses due to low blood flow to the affected limb. RESULTS This patient underwent endovascular intervention and placement of stents to restore the flow to the limbs. CONCLUSION It is feasible to assume that continuous and direct pressure on the inguinal region during surgery on Jackson table was the primary cause of the iliac artery occlusion, particularly in these patients with known peripheral vascular disease. Early recognition and prompt vascular intervention can prevent serious sequelae.
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Fantini GA, Pawar AY. Access related complications during anterior exposure of the lumbar spine. World J Orthop 2013; 4:19-23. [PMID: 23362471 PMCID: PMC3557318 DOI: 10.5312/wjo.v4.i1.19] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 12/18/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023] Open
Abstract
The new millennium has witnessed the emergence of minimally invasive, non-posterior based surgery of the lumbar spine, in particular via lateral based methodologies to discectomy and fusion. In contrast, and perhaps for a variety of reasons, anterior motion preservation (non-fusion) technologies are playing a comparatively lesser, though incompletely defined, role at present. Lateral based motion preservation technologies await definition of their eventual role in the armamentarium of minimally invasive surgical therapies of the lumbar spine. While injury to the major vascular structures remains the most serious and feared complication of the anterior approach, this occurrence has been nearly eliminated by the use of lateral based approaches for discectomy and fusion cephalad to L5-S1. Whether anterior or lateral based, non-posterior approaches to the lumbar spine share certain access related pitfalls and complications, including damage to the urologic and neurologic structures, as well as gastrointestinal and abdominal wall issues. This review will focus on the recognition, management and prevention of these anterior and lateral access related complications.
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Hrabalek L, Adamus M, Gryga A, Wanek T, Tucek P. A comparison of complication rate between anterior and lateral approaches to the lumbar spine. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 158:127-32. [PMID: 23073535 DOI: 10.5507/bp.2012.079] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 07/19/2012] [Indexed: 02/07/2023] Open
Abstract
AIM The aim of this study was to compare the complication rate of traditional minimally invasive anterior with the new minimally invasive lateral trans-psoatic retroperitoneal approaches to the intervertebral discs at levels T12-L5. METHODS A review of all cases of minimally invasive anterior (ALIF) and lateral (XLIF) intervertebral disc surgery at levels T12-L5, treated at the Department of Neurosurgery from January 1996 to September 2011. The ALIF group consisted of 120 and the XLIF group consisted of 88 patients. Preoperative diagnoses were: degenerative disc disease, failed back surgery syndrome, spondylolisthesis, retrolisthesis and posttraumatic disc injury. The surgical steps are described. All surgical intraoperative and postoperative complications directly related to the spinal surgery were prospectively documented. The outcome measure was rate of complications. RESULTS In the ALIF group there were no major complications, only 35 minor intra- and postoperative complications in 32 patients (26.6%). The main complication was lumbar post-sympathectomy syndrome in 19 patients (15.8%). In the XLIF group there were 26 complications in 22 patients (25%). One major intraoperative complication was partial and transient injury to the L5 nerve root (1.1%). There were 25 minor postoperative complications in the XLIF group in 21 patients (23.9%), mainly transient pain of the left groin or anterior thigh in 11 patients (12.5%) or numbness in the same dermatomas in 9 patients (10.2%). Statistically there was no difference between the ALIF and XLIF groups in complication rate. CONCLUSION Anterolateral and lateral retroperitoneal minimally invasive approaches to levels T12-L5 disc spaces are safe procedures with only minor complications and one exception. The rate of complications was similar in both groups. In the case of ALIF, the particular complication was post-sympathectomy syndrome. The main complication of XLIF was transient nerve root injury in one patient due to underestimation of the procedure in the outset. Intraoperative neuromonitoring during XLIF surgery is fully recommended.
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Affiliation(s)
- Lumir Hrabalek
- Department of Neurosurgery, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Asha MJ, Choksey MS, Shad A, Roberts P, Imray C. The role of the vascular surgeon in anterior lumbar spine surgery. Br J Neurosurg 2012; 26:499-503. [DOI: 10.3109/02688697.2012.680629] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Midline anterior approach from the right side to the lumbar spine for interbody fusion and total disc replacement: a new mobilization technique of the vena cava. Spine (Phila Pa 1976) 2012; 37:E562-9. [PMID: 22517482 DOI: 10.1097/brs.0b013e31823a0a87] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study. OBJECTIVE To describe a midline anterior approach to the lumbar spine from the right side, below the aortic bifurcation to L5-S1, and by mobilizing the vena cava from right to left between L2 and L5. Feasibility and complication rate related to the approach have been studied. SUMMARY OF BACKGROUND DATA Midline anterior approach to the lumbar spine has developed during these last years, mainly for interbody fusion and disc arthroplasty surgery. This retroperitoneal approach is well described in publications and classically made from the left side. Major complications associated with the approach are known: retrograde ejaculation, venous injuries, and arterial thrombosis. METHODS A total of 469 patients were included in a prospective study between August 2003 and November 2010, either for interbody fusion by anterior approach or for total disc replacement, on one or several levels between L2-L3 and L5-S1. RESULTS On the 154 patients who had a mobilization of the vena cava, no injury occurred. Only 4 major venous injuries occurred. There was no arterial complication, and the oxygen saturation signal was interrupted in only 1 case. No case of retrograde ejaculation was found. CONCLUSION The midline anterior retroperitoneal approach from the right side is a safe alternative compared with the classical approach from the left side. The low rate of venous injury is explained by the sidewall thickness of the vena cava compared with the left iliac vein sidewall. Contrary to what happens by left-sided approach, the vascular retraction required for access to L4-L5 and above does not lead to arterial occlusion and therefore diminishes the risk in atheromatous patients. The absence of retrograde ejaculation confirms previous studies conducted on the left anastomosis of the superior hypogastric plexus, suggesting that its approach and mobilization by the left side are delicate.
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Than KD, Wang AC, Rahman SU, Wilson TJ, Valdivia JM, Park P, La Marca F. Complication avoidance and management in anterior lumbar interbody fusion. Neurosurg Focus 2011; 31:E6. [DOI: 10.3171/2011.7.focus11141] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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König MA, Leung Y, Jürgens S, MacSweeney S, Boszczyk BM. The routine intra-operative use of pulse oximetry for monitoring can prevent severe thromboembolic complications in anterior surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:2097-102. [PMID: 21800033 DOI: 10.1007/s00586-011-1900-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 06/28/2011] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Anterior access to the lumbar spine is established for disc replacement surgery and anterior interbody fusion in the lumbar spine. The spine is accessed normally from the left side either by a transperitoneal or retroperitoneal approach through a midline or oblique skin incision. After reaching the retroperitoneum and depending on the level of exposure, the surgeon has to mobilise and retract the aorta or left common iliac artery, as well as the left common iliac vein or internal vena cava to the right lateral border to address the whole disc space. The left common iliac artery is especially stretched during intervertebral disc exposure putting it at a greater risk of adverse events. Not surprisingly, vascular adverse events like direct injuries, thrombosis and embolism are feared complications in anterior surgery. Permanent intra-operative left leg oxygen saturation surveillance via pulse oximetry can help detecting embolic situations thereby allowing immediate treatment minimising the leg ischemia or preventing limb loss. CASE REPORT In the presented case, a 61-year-old male patient undergoing a two-level anterior interbody fusion lost oxygen saturation in the left leg after vessel retraction for exposure. After cage insertion and release of the retractor blades, the pulse oximetry signal did not return and no pulses were found during instant Doppler investigation below the femoral artery, indicating severe embolism in the left leg. The left common iliac artery was clamped and opened showing a ruptured calcified plaque with adherent fresh thrombotic material. An endovascular embolectomy in the superficial and deep femoral artery revealed several small thrombi. An artherectomy of the common iliac artery followed by patch closure was performed. Immediately after clamp release, pulse oximetry returned and Doppler signals were detectable at the tibialis posterior and dorsalis pedis artery. Post-operative recovery was uneventful and pulses were palpable at all times. CONCLUSION Arterial adverse events in anterior access surgery are rare complications but none the less, it is of paramount importance to detect and treat these situations immediately. This case highlights the need of routine pulse monitoring during the whole anterior surgery to prevent embolic complications. Even manual pulse control might not be sufficient to rule out any distal embolic events creating severe leg ischemia.
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Affiliation(s)
- M A König
- The Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK.
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Abstract
The incidence of anterior lumbar surgery is increasing. Although adverse events are uncommon, several have been described. Complications can be categorized based on the time of occurrence (ie, intraoperative, postoperative), patient positioning, surgical exposure, and spinal procedure. Notable approach-related complications involve vascular, visceral, and neural structures. Abdominal complications have been reported. Clinically significant complications related to spinal decompression and reconstruction consist primarily of neurologic injuries and graft- and device-related problems. The rate of complications is higher in the setting of revision anterior surgery than with initial anterior lumbar surgery. A thorough understanding of the complications associated with anterior lumbar surgery will aid in prevention, recognition, and management of these rare problems. The assistance of a vascular, neurologic, or general surgeon may be helpful in avoiding or effectively managing complications.
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El cirujano vascular y la cirugía mínimamente invasiva de la columna lumbar: complicaciones vasculares durante 9 años. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
This article presents a case of a patient with popliteal artery occlusion following anterior and posterior instrumented fusion of the lumbar spine. No previous study has reported acute anterior tibial compartment syndrome due to popliteal artery occlusion and restricted venous return following spine surgery. A 53-year old female, with a twice failed fusion of L5-S1, underwent L3-S1 anterior interbody and posterior L3-S1 instrumented fusion. Due to postoperative continuous analgesia, the patient was sleepy and confused on postoperative day 1. On the postoperative day 2, the right calf and anterolateral tibia manifested clinical signs of compartment syndrome and both thighs exhibited pressure ecchymoses from the antiembolism stockings. Fasciotomies of the right tibial compartments were undertaken and necrosis of the anterior compartment muscles was found. Intraoperative arteriogram revealed occlusion of the right popliteal artery and thrombectomy was performed. Lupus anticoagulant was found to be responsible for patient's coagulopathy. During postoperative year 1, the patient still had weakness and recurrent edema of the right foot. Unrecognized limb ischemia and possibly restricted venous return were the causes of the compartment syndrome. Surgeons should be aware of this devastating complication of spine surgery.
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Changes in abdominal vascular tension associated with various leg positions in the anterior lumbar approach: cadaver study. Spine (Phila Pa 1976) 2010; 35:1026-32. [PMID: 20393396 DOI: 10.1097/brs.0b013e3181bee999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A descriptive cadaveric study measuring arterial tension. OBJECTIVE Anterior lumbar surgery is technically challenging due to perioperative vascular complications. Many studies suggest approaches based on the anatomy of the abdominal vessel for safe vascular mobilization. However, the tension in the vascular structure is also important for adequate exposure of the target lesion. It has been established that the tension in the lumbar nerve at the root level can be changed by a straight leg raise test and that the structure of the vascular connection is similar to that of the neural connection. Consequently, a change in leg position could affect the tension of lumbosacral vessels. The purpose of this study was to evaluate the effect of leg position on the tension of lumbosacral vessels. METHODS We dissected 10 unembalmed cadavers using the method described by Gumbs et al, using the Synframe system to expose the abdominal artery and vein. The left iliac artery and the distal abdominal aorta were retracted to the right side at the L4-L5 disc level by a measuring retractor to which a strain gauge was attached. The tension was checked at various angles of the hip joint and the motions of the abdominal arteries were monitored in 4 unembalmed cadavers using a C-arm fluoroscope. RESULTS The tension in the abdominal aorta at L4-L5 level was decreased by 2.9% to 21.8% in the hip-flexion position, and the motion of the arteries showed proximal displacement of the external iliac artery and the common iliac artery during the hip-flexed position and veins also showed the same pattern of displacement as artery. CONCLUSION The results of this study would be useful for not only spinal surgery but also other vascular surgeries, particularly, in cases where patients with conditions such as atherosclerosis or stenosis.
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE To document the incidence and consequences of vascular injury in lumbosacral surgery, to identify factors contributing to this injury, and to determine whether there are any effective measures to decrease the occurrence of vascular injury. SUMMARY OF BACKGROUND DATA Anterior lumbosacral surgery encompasses all aspects of spine surgery, including trauma, deformity, and degenerative conditions. Although it has theoretical advantages, anterior lumbosacral surgery carries with it certain definite risks, one of the most critical of which is injury to the surrounding vasculature. It is important for both the patient and the surgeon to understand the risks, patterns, and outcomes of injury to the vascular structures associated with this surgery. METHODS A systematic review of the English-language literature was undertaken for articles published between January 1993 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining vascular injury in anterior lumbosacral surgery. Vascular injury was defined as any case in which a suture was required to control bleeding. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. RESULTS A total of 88 articles were initially screened, and 40 ultimately met the predetermined inclusion criteria. Vascular injuries after anterior lumbosacral surgeries were rare (<5%). Venous laceration was more common than arterial laceration, and most venous injuries occurred during retraction of the great vessels. In most cases, the overall clinical outcome after vascular injury was not adversely affected. L4-L5 exposure was associated with increased vascular injury in some studies but not others. Vascular injury occurred more frequently in laparoscopic compared with open anterior lumbar interbody fusion. CONCLUSION Vascular injury in anterior lumbosacral surgery remains low, with reports being <5%. The consequences of injury seem rare, but may include thrombosis, pulmonary embolism, and prolonged hospitalization. Exposure and surgery at L4-L5 may be associated with a higher risk of injury than that at L5-S1, though the data are not consistent.
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Nair MN, Ramakrishna R, Slimp J, Kinney G, Chesnut RM. Left iliac artery injury during anterior lumbar spine surgery diagnosed by intraoperative neurophysiological monitoring. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19 Suppl 2:S203-5. [PMID: 20401621 DOI: 10.1007/s00586-010-1372-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 02/28/2010] [Accepted: 03/07/2010] [Indexed: 11/28/2022]
Abstract
Serious vascular injury is a rare, but potentially devastating complication during anterior lumbar spinal surgery. The authors describe the first reported case where vascular injury was detected by multimodality neurophysiological monitoring during an L3-S1 anterior lumbar interbody fusion. The case demonstrates the need for multi-modality monitoring and the combined use of somatosensory-evoked potentials and motor-evoked potentials.
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Affiliation(s)
- M Nathan Nair
- Department of Neurological Surgery, Harborview Medical Center, University of Washington School of Medicine, Box 359766, Patricia Steel Bldg 401 Broadway, Seattle, WA 98104, USA
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