Does improved radiographic alignment truly enhance dynamic functional balance?

Prospective, concurrent-cohort study. To establish the relationship between radiographic alignment parameters and functional CoE measurements at one week before and at three months after realignment surgery in ADS patients. Adult degenerative scoliosis (ADS) represents a significant healthcare burden with exceedingly high and increasing prevalence, particularly among the elderly. Radiographic alignment measures and patient-reported outcomes currently serve as the standard means to assess spinal alignment, deformity, and stability. Neurological examinations have served as qualitative measures for indicating muscle strength, motor deficits, and gait abnormalities. Three-Dimensional motion analysis is increasingly being used to identify and measure gait and balance instability. Recently, techniques have been established to quantify balance characteristics described by Dubousset as the "cone of economy" (CoE). The relationship between radiographic alignment parameters and CoE balance measures of ADS patients before and after realignment surgery is currently unknown. 29 ADS patients treated with realignment surgery. Patients were evaluated at one week before realignment surgery and at their three-month follow-up examination. During each evaluation, patients completed self-reported outcomes (visual analog scales for pain, Oswestry Disability Index, SRS22r) and a functional balance test. Mean changes in dependent measures from before to after surgery were compared using paired t-tests. Pearson correlations were used to test for significant correlations between changes in radiographic and CoE measures. Significant improvements were found for all patient-reported outcomes, in several radiographic measures, and in CoE measures. Improvements of scoliosis Cobb angle, coronal pelvic tilt, lumbar lordosis, and thoracic kyphosis showed significant correlations with CoE sway and total distance measures at both the center of mass and center of the head. Improved radiographic alignment measures significantly correlated with improved CoE balance measures among ADS patients treated with realignment surgery at their three-month follow-up. These findings indicate that functional balance evaluations when used in conjunction with radiographic measurements, may provide a more robust and improved patient-specific sensitivity for postoperative assessments. CoE balance may represent a new measure of added value for surgical intervention of ADS.

The effect of scoliosis support orthosis bracing on adult spinal deformity patients: evaluation of gait and dynamic balance.

Non-operative treatment is regarded as the first-line therapy for patients with adult spinal deformity (ASD) without neurologic deficits or significant impairment. While there is high-level evidence supporting the use of rigid bracing in adolescent idiopathic scoliosis, there is a paucity of literature pertaining to the use of scoliosis support orthosis (SSO) in ASD patients. To investigate the impact of an SSO on pain, gait parameters, and functional balance measures in symptomatic ASD patients. Thirty ASD patients (26 Females, Age: 72.7, Cobb Angle: 47.1°) were evaluated on 3 different occasions: first day of bracing: baseline (Pre), and 45-min post fitting (Post45m), and after 8-weeks of bracing for 4 hours a day (Post8w). Each patient performed a 6-minute walk (over-ground gait), a dynamic balance test, and completed VAS, ODI, and SRS22r. Significant short- and long-term improvements using SSO were found in the 6-minute walk (Pre: 278.6; Post45m: 322.2; Post8w: 338.8 m, p<0.001), walking speed (Pre: 0.88; Post45m: 0.97; Post8w: 0.97 m/s, p<0.001), head total sway distance during the balance test (Pre: 81.33; Post45m: 68.63; Post8w: 60.72 cm, p=0.048), low-back pain (VAS: Pre: 5.5; Post45m: 3.5; Post8w: 3.3, p<0.001), and for the ODI (Pre: 41.9; Post45m: 32.9; Post8w: 30.1, p=0.005).This study demonstrated clinically significant improvements in PROMs, spatiotemporal gait measures, and functional balance measures after continuous use of a SSO. These improvements were observed immediately following brace-fitting and maintained at an 8-week follow-up. Given these results, it is reasonable to consider a SSO for conservative management of patients with mild symptoms of pain and deformity, and who have not yet progressed to meet surgical indications.

Virulence of major periodontal pathogens and lack of humoral immune protection in a rat model of periodontal disease.

OBJECTIVE: This study was designed to test the hypothesis that periodontal pathogens Tannerella forsythia and Porphyromonas gingivalis are synergistic in terms of virulence potential using a model of mixed-microbial infection in rats. MATERIALS AND METHODS: Three groups of rats were infected orally with either T. forsythia or P. gingivalis in mono-bacterial infections or as mixed-microbial infections for 12 weeks and a sham-infected group were used as a control. This study examined bacterial infection, inflammation, immunity, and alveolar bone loss changes with disease progression. RESULTS: Tannerella forsythia and P. gingivalis genomic DNA was detected in microbial samples from infected rats by PCR indicating their colonization in the rat oral cavity. Primary infection induced significantly high IgG, IgG2b, IgG1, and IgG2a antibody levels indicating activation of mixed Th1 and Th2 immune responses. Rats infected with the mixed-microbial consortium exhibited significantly increased palatal horizontal and interproximal alveolar bone loss. Histological examinations indicated significant hyperplasia of the gingival epithelium with moderate inflammatory infiltration and apical migration of junctional epithelium. The results observed differ compared to uninfected controls. CONCLUSION: Our results indicated that T. forsythia and P. gingivalis exhibit virulence, but not virulence synergy, resulting in the immuno-inflammatory responses and lack of humoral immune protection during periodontitis in rats.

Robotic assisted spinal surgery--from concept to clinical practice.

After several years of product development, animal trials and human cadaver testing, the SpineAssist--a miniature bone-mounted robotic system--has recently entered clinical use. To the best of the authors' knowledge, this is the only available image-based mechanical guidance system that enables pedicle screw insertion with an overall accuracy in the range of 1 mm in both open and minimally invasive procedures. In this paper, we describe the development and clinical trial process that has brought the SpineAssist to its current state, with an emphasis on the various difficulties encountered along the way and the corresponding solutions. All aspects of product development are discussed, including mechanical design, CT-to-fluoroscopy image registration, and surgical techniques. Finally, we describe a series of preclinical trials with human cadavers, as well as clinical use, which verify the system's accuracy and efficacy.

Chronic pain and obstetric management of a patient with tuberous sclerosis.

Chronic nonmalignant pain is very disabling and carries a heavy financial strain on the individual and society as a whole. This case describes a woman with tuberous sclerosis, in her fourth pregnancy. Approximately 18 months prior to pregnancy, intractable left loin pain, thought to be secondary to hemorrhage within a tuberous lesion in the left kidney, had led to the siteing of an intrathecal morphine pump. The risks of system failure (dislodgement, dislocation), escalating dosage, infection, use in labor, and neonatal opioid withdrawal are all explored and discussed. While data are limited, with increasing use of intrathecal opioids for nonmalignant pain, such patients may be seen more regularly in obstetric clinics. With a multidisciplinary team approach, risks can be minimized and outcome for mother and baby optimized.

Management of complex regional pain syndrome type II using lidoderm 5% patches.

We report a case of a patient developing complex regional pain syndrome of the upper limb after a laceration injury with glass. The pain in his hand was resistant to all conventional modes of treatment. The pain reduced dramatically after a diagnostic lidocaine infusion and the reduction in pain lasted for 3 days. Following this the patient responded well to lidoderm 5% patches and achieved 80% pain relief with an improved range of movement in his hand.

Functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures.

INTRODUCTION: Vertebral body compression fractures secondary to osteoporosis or malignant osteolysis are an increasingly common problem. The primary purpose of our study was to assess functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures. Our secondary purpose was to compare such functional outcomes in patients with osteoporosis versus multiple myeloma. METHODS: The 314 consecutive patients prospectively included in our study had progressive and painful compression fractures as a result of osteoporosis or multiple myeloma that were refractory to nonoperative modalities. Of those 314 patients, the 211 (67.2%) patients (155 with osteoporosis and 56 with multiple myeloma) who had complete preoperative and postoperative data formed our final study group. All patients tolerated the kyphoplasty procedure well (that is, there were no adverse events in terms of perioperative patient condition). Follow-up ranged from 1 to 235 weeks (mean 55.0 weeks). Functional outcomes were assessed by the SF-36 and Oswestry Disability Index at baseline and at follow-up examinations. Data were analyzed by Student's t-test and the level of significance was set at P

Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma.

PURPOSE: We prospectively evaluated the safety and efficacy of kyphoplasty in the treatment of osteolytic vertebral compression fractures resulting from multiple myeloma. The principle symptoms in multiple myeloma result from bone destruction, especially the spine. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps (IBT) into the vertebral body. The purpose of the IBT is to restore the vertebral body back toward its original height, while creating a cavity that can be filled with highly viscous bone cement. PATIENTS AND METHODS: Fifty-five consecutive kyphoplasty procedures were performed in 18 patients with osteolytic vertebral compression fractures resulting from multiple myeloma. Cement leakage and any complications were recorded. Early objective analysis was made by comparing preoperative and latest Short Form 36 Health Survey scores. Height restoration was estimated by measuring vertebral height on lateral radiographs. RESULTS: The mean age of patients was 63.5 years, mean duration of symptoms was 11 months, and mean follow-up was 7.4 months. There were no major complications related directly to use of this technique. On average, 34% of height lost at the time of fracture was restored. Asymptomatic cement leakage occurred at two (4%) of 55 levels. Significant improvement in SF36 scores occurred for Bodily Pain (23.2 to 55.4, P =.0008), Physical Function (21.3 to 50.6, P =.0010), Vitality (31.3 to 47.5, P =.010), and Social Functioning (40.6 to 64.8, P =.014). CONCLUSION: Kyphoplasty was efficacious in the treatment of osteolytic vertebral compression fractures resulting from multiple myeloma. Kyphoplasty is associated with early clinical improvement of pain and function as well as some restoration of vertebral body height.

Laparoscopic lateral L4-L5 disc exposure.

BACKGROUND: The anterior laparoscopic approach requires precarious dissection around the iliac vessels to expose the L4-L5 level. Furthermore, a retroperitoneal endoscopic approach to the L4-L5 level requires a technically demanding dissection to access the L5-S1 disc space. A unique lateral laparoscopic approach to the L4-L5 disc space allows concurrent access to the L5-S1 space while avoiding major dissection around the iliac vessels. This article describes this novel lateral approach and reviews the initial clinical outcomes. METHODS: Between January 1999 and April 2000, five patients underwent laparoscopic lateral L4-L5 disc exposure at the Cleveland Clinic Foundation. All charts were reviewed retrospectively. Mean values +/- standard deviation were determined for patient demographics and operative characteristics. A standard five-port laparoscopic technique was used. The sigmoid colon was retracted medially with an endoloop. The retroperitoneum was entered and the ureter and left iliac artery were retracted medially, whereas the psoas was retracted laterally. Fluoroscopy delineated the L4-L5 disc space allowing discectomy and cage insertion. Postoperatively, subjective patient satisfaction was obtained and radiologic evidence of fusion was assessed. RESULTS: All five patients were males, with a mean age of 47.4 +/- 7 years and a body mass index of 30 +/- 6 kg/m2. Four patients had an L4-L5 and L5-S1 fusion and one patient had an L4-L5 and L3-L4 fusion. Mean operative time was 349 +/- 32 min, with a mean blood loss of 210 +/- 74 cc. There were no intraoperative complications and no conversions, and postoperatively all patients were started on a clear liquid diet on postoperative day 1. The mean length of stay was 3.4 +/- 0.9 days. Patients returned to work in a mean of 12 +/- 7 weeks. All patients had evidence of fusion on their radiologic follow-up. Four patients were pain free, whereas one patient required intermittent narcotics at 1-year follow-up. CONCLUSIONS: For multilevel fusions including the L4-L5 disc space, the lateral laparoscopic exposure is a safe and efficacious procedure allowing simultaneous access to multiple disc spaces while avoiding the sympathetic chain, ureter, and major vascular structures. The lateral approach affords excellent exposure for accurate deployment of the appropriate orthopedic hardware.

Initial outcome and efficacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures.

STUDY DESIGN: An Institutional Review Board-approved Phase I efficacy study of inflatable bone tamp usage in the treatment of symptomatic osteoporotic compression fractures. OBJECTIVES: To evaluate the safety and efficacy of inflatable bone tamp reduction and cement augmentation, "kyphoplasty," in the treatment of painful osteoporotic vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Osteoporotic compression fractures can result in progressive kyphosis and chronic pain. Traditional treatment for these patients includes bed rest, analgesics, and bracing. Augmentation of vertebral compression fractures with polymethylmethacrylate, "vertebroplasty," has been used to treat pain. This technique, however, makes no attempt to restore the height of the collapsed vertebral body. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps into the vertebral body. Once inflated, the bone tamps restore the vertebral body back toward its original height while creating a cavity that can be filled with bone cement. PATIENTS AND METHODS: Seventy consecutive kyphoplasty procedures were performed in 30 patients. The indications included painful primary or secondary osteoporotic vertebral compression fractures. Mean duration of symptoms was 5.9 months. Symptomatic levels were identified by correlating the clinical data with MRI findings. Perioperative variables and bone tamp complications or issues were recorded and analyzed. Preoperative and postoperative radiographs were compared to calculate the percentage height restored. Outcome data were obtained by comparing preoperative and latest postoperative SF-36 data. RESULTS: At the completion of the Phase I study there were no major complications related directly to use of this technique or use of the inflatable bone tamp. In 70% of the vertebral bodies kyphoplasty restored 47% of the lost height. Cement leakage occurred at six levels (8.6%).SF-36 scores for Bodily Pain 11.6-58.7, (P = 0.0001) and Physical Function 11.7-47.4, (P = 0.002) were among those that showed significant improvement. CONCLUSIONS: The inflatable bone tamp was efficacious in the treatment of osteoporotic vertebral compression fractures. Kyphoplasty is associated with early clinical improvement of pain and function as well as restoration of vertebral body height in the treatment of painful osteoporotic compression fractures.

Thoracoscopic transdiaphragmatic adrenalectomy: the initial experience.

PURPOSE: We introduce the technique of thoracoscopic transdiaphragmatic adrenalectomy. MATERIALS AND METHODS: Initially in 4 human cadavers bilateral thoracoscopic nephrectomy was performed to develop the technique of diaphragmatic incision, retroperitoneal control of renal artery and vein, circumferential mobilization of the kidney and adrenal gland, and suture repair of the diaphragm. Subsequently, 3 select patients underwent thoracoscopic transdiaphragmatic adrenalectomy (2 right side and 1 left side). All 3 patients had significant prior abdominal scarring after either partial or total radical nephrectomy, thereby precluding efficient transabdominal laparoscopic access to the adrenal gland. After double lumen endotracheal intubation, a 4 port transthoracic approach without pneumo-insufflation was performed with the patient in the prone position. The diaphragm was incised under real-time laparoscopic ultrasound guidance. The adrenal gland was visualized high in the retroperitoneum, the vasculature controlled, and the specimen entrapped and extracted intact through a thoracic port site. The diaphragm was suture repaired with freehand laparoscopic suturing and intracorporeal knot tying. A chest tube was inserted in the initial 2 patients. RESULTS: There were no intraoperative or postoperative complications. Operating time was 4.5, 6.5 and 2.5 hours, and blood loss was 150, 500 and 50 cc, respectively. Mean narcotic analgesic requirement was 27 mg. morphine sulfate equivalent. Hospital stay was 2 days for all 3 patients. Pathology revealed metastatic renal cell carcinoma in 2 patients and myelolipoma in 1. CONCLUSIONS: In select patients with significant concomitant intraperitoneal and retroperitoneal scarring from prior major abdominal or renal surgery laparoscopic adrenalectomy can be safely performed with the transthoracic transdiaphragmatic approach. We present our initial experience.

Three-dimensional computed tomographic volume rendering techniques in endoscopic thoracoplasty.

BACKGROUND CONTEXT: Thoracoplasty is occasionally necessary to achieve an acceptable cosmetic result in the presence of a rib hump, especially in previously fused young adults with scoliosis. This usually requires the resection of four to five rib segments, and the morbidity associated with open posterior resection or of open anterior resection by means of thoracotomy is often considerable, apart from leaving an unsightly scar. We thought the use of an endoscopic internal rib resection technique would achieve the desired result with less morbidity. Our experience with using the technique of three-dimensional (3-D) computed tomographic (CT) volume rendering to plan our portals and releases for endoscopic scoliosis correction led us to believe the same techniques could be adapted to plan and endoscopically carry out the thoracoplasty. PURPOSE: To define the utility of 3-D CT volume rendering of the spine and thorax in the preoperative planning of endoscopic rib resection. STUDY DESIGN: A prospective evaluation of the utility of 3-D CT volume rendering for preoperative planning in patients with scoliosis undergoing endoscopic thoracoplasty for correction of rib humps. PATIENT SAMPLE: Four consecutive patients with previously fused scoliotic spines and pronounced right-sided rib humps requiring operative correction were selected. OUTCOME MEASURES: Outcome was assessed at a minimum follow-up of 6 months by clinical examination, patient satisfaction with the clinical result, and repeat helical CT scanning with 3-D reconstruction. METHODS: Four patients with previously fused scoliotic spines and pronounced rib humps underwent helical CT scanning with 3-D volume rendering, prior to endoscopic corrective surgery. All four patients had right-sided rib humps requiring corrective rib resection for cosmetic reasons. Using the technique of 3-D volume rendering, a vector plane was created to mirror the left scapula, and its intersections on the right chest wall were noted. The ribs to be resected were marked, and the length of rib resection was measured from the vector plane's intersection points with the ribs. In this way an estimate of the resection required to achieve the desired final position of the right elevated scapula could be determined. Entry portals were also estimated with vector lines to achieve optimal access to each rib. During surgery, the portal sites were assessed for access to the selected ribs. Also, the extent of rib resections was compared with the estimates. The final clinical outcome was assessed by clinical examination, patient satisfaction with the cosmetic result, and repeat helical CT scanning with 3-D reconstruction. RESULTS: The male to female ratio was 1:3, and the average age was 21 years. Our average estimated blood loss was 307 ml and average hospital stay was 4.75 days. The estimated portal sites were accurate and did provide for direct access to each selected rib involved in the deformity. We were able to resect the ribs at the points suggested by 3-D CT volume rendering, with the lengths of our resected segments matching our preoperative estimates. In all cases the elevated right scapula did descend into the rib resection bed, thus balancing the shoulder heights. An excellent cosmetic result was achieved in all cases as evaluated by clinical examination, patient's perception, and repeat helical CT scanning. CONCLUSION: The technique of 3-D CT volume rendering with vector plane estimates provides a reliable estimate of the rib resection required to achieve a cosmetically acceptable correction of the rib hump through minimally invasive techniques.

Laparoscopic lumbar interbody spinal fusion.

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

Prone position endoscopic transthoracic release with simultaneous posterior instrumentation for spinal deformity: a description of the technique.

STUDY DESIGN: A prospective series of 15 consecutive adult patients with spinal deformity who underwent endoscopic transthoracic release with simultaneous posterior instrumentation while positioned prone. OBJECTIVES: To describe the technique and clinical results of endoscopic transthoracic release performed with the patient prone (as opposed to lateral) on the concave side for scoliosis or on either side for kyphosis, with simultaneous posterior exposure, instrumentation, and correction of the deformity. SUMMARY OF BACKGROUND DATA: Use of endoscopic surgical techniques is rapidly advancing across all subspecialties. These techniques can be used to expose and operate on the spine in a less invasive fashion, thus avoiding damage to other tissues and facilitating earlier mobilization and rehabilitation. Current endoscopic techniques with the patient in the lateral decubitus position mimic open thoracotomy. A new technique is described with the patient positioned prone, which allows simultaneous posterior exposure. METHODS: Preoperative Cobb angle or thoracic kyphosis angle, maximal correction bending films, and postoperative Cobb angle or kyphosis angle were measured and compared. All perioperative morbidity, intraoperative complications, and surgical variables were prospectively documented and analyzed. RESULTS: There were no intraoperative technical problems with the endoscopic equipment or instruments and no immediate, 6-month, or 2-year postoperative complications related to the endoscopic component of the procedure. In the scoliosis patients, the average correction was 60%. In the kyphosis patients, the average correction was 39%. CONCLUSIONS: Transthoracic endoscopic techniques, compared with thoracotomy, offer a less invasive method of accessing the anterior spinal column, with the benefits of an excellent view of the area of the spine being instrumented, minimal soft tissue disruption, and an improved cosmetic result. With the simultaneous technique, staged or subsequent procedures can be eliminated, and a circumferential structural release as well as control of the mobilized spine can be achieved. This simultaneous technique can be extended for use in correction of a variety of thoracic spinal pathologies.

Endoscopic approaches to metastatic thoracic disease.

Traditional approaches to thoracic metastases and spinal cord compression have been well worked out and validated in the literature. Anterior decompression is clearly superior to laminectomy; vertebrectomy and reconstruction are indicated for sagittal collapse, instability, and pain; and surgical decompression is necessary in cases of bony impingement. The role of endoscopic and minimally invasive techniques in treatment of metastatic disease is evolving. Dr. Lieberman advocates the use of thoracoscopic anterior approaches as the principal application in these patients, whereas Dr. McLain has found that endoscopic assistance has vastly improved his results with posterolateral decompression. The two authors weigh the relative advantages and disadvantages of these approaches for the selected patient with metastatic thoracic disease.

Transperitoneal laparoscopic exposure for lumbar interbody fusion.

STUDY DESIGN: A prospective clinical trial of the transperitoneal laparoscopic approach to the lumbar spine in a consecutive series of patients undergoing anterior lumbar interbody fusion. OBJECTIVES: To determine safety and effectiveness, and to document technique and perioperative complications of a laparoscopic exposure for lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: With the widespread adoption of laparoscopic techniques, the benefits of minimal access surgery are now well recognized--in general, gynecologic and urologic surgery. Only recently have minimal access techniques been applied to spinal procedures. METHODS: Forty-seven patients with symptomatic degenerative disc disease underwent transperitoneal laparoscopic exposure of the lumbar spine to facilitate implantation of cylindrical threaded interbody fusion cages. These patients were prospectively followed and all perioperative considerations and complications were documented and analyzed. The surgical technique of laparoscopic exposure will be described. RESULTS: The laparoscopic approach was attempted in 47 consecutive patients. Forty-four were completed laparoscopically--36 single level fusions, seven two level fusions, and one three level fusion. Early in the series, conversion to open surgery was required in one patient (case #3) because of bleeding from the presacral veins which hindered the view. In one case, mobilization of the great vessels proved to be difficult, and in one other case the patient could not tolerate abdominal insufflation. The mean blood loss for the entire group was 105 mls. Complications related to the endoscopic exposure were few. There were no injuries to major vascular structures or to bowel, and no mortalities. In two patients, the cages were malpositioned necessitating repeat endoscopic exposure for cage realignment. One patient required a laparotomy for a postoperative small bowel obstruction. The median postoperative stay was 4 days. CONCLUSIONS: Transperitoneal laparoscopic exposure for single or multiple level, anterior lumbar interbody fusion can be performed with low risk. Experience in open anterior spinal surgery and laparoscopic general surgery is vital in minimizing the risks.