Transumbilical Retroperitoneal Lumbar Interbody Fusion: A Technical Note and Preliminary Case Series.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) has advantages over posterior lumbar interbody fusion or transforaminal lumbar interbody fusion techniques in that it minimizes damage to the anatomical structure of the posterior spinal segment and enables indirect decompression of the foramen by insertion of a tall cage. However, the predominant abdominal scar tissue reduces patients' satisfaction after ALIF. Herein, we describe the technique of transumbilical lumbar interbody fusion (TULIF) and its preliminary results in a case series. METHODS: A retrospective review of 154 consecutive patients who underwent TULIF between the L2-3 and L4-5 levels was performed. After preoperatively selecting patients by evaluating the location of the umbilicus and vessel anatomy, a vertical skin incision was made on the umbilicus to minimize the abdominal scar tissue. RESULTS: There were 120 single-level (110 L4-5 and 10 L3-4), 31 two-level, and 3 three-level surgeries. All patients were very satisfied with their postoperative abdominal scars, which were noticeably faint compared to those after conventional ALIF. CONCLUSION: TULIF is a feasible, minimally invasive surgical option that can achieve both the treatment of degenerative spinal disease and satisfactory cosmesis. Although it is technically demanding, patients obtain sufficient benefits.

An analysis of general surgery-related complications in a series of 412 minilaparotomic anterior lumbosacral procedures.

OBJECT: Anterior lumbar surgery is associated with certain perioperative visceral and vascular complications. The aim of this study was to document all general surgery-related adverse events and complications following minilaparotomic retroperitoneal lumbar procedures and to discuss strategies for their management or prevention. METHODS: The authors analyzed data obtained in 412 patients who underwent anterior lumbosacral surgery between 2003 and 2005. The series comprised 114 men and 298 women whose mean age was 56 years (range 34-79 years). Preoperative diagnoses were as follows: isthmic spondylolisthesis (32%), degenerative spondylolisthesis (24%), instability/stenosis (15%), degenerative disc disease (15%), failed-back surgery syndrome (7%), and lumbar degenerative kyphosis or scoliosis (7%). A single level was exposed in 264 patients (64%), 2 in 118 (29%), and 3 or 4 in 30 (7%). The average follow-up period was 16 months. RESULTS: Overall, 52 instances of complications and adverse events occurred in 50 patients (12.1%), including sympathetic dysfunction in 25 (6.06%), vascular injury repaired with/without direct suture in 12 (2.9%), ileus lasting > 3 days in 5 (1.2%), pleural effusion in 4 (0.97%), wound dehiscence in 2 (0.49%), symptomatic retroperitoneal hematoma in 2 (0.49%), angina in 1 (0.24%), and bowel laceration in 1 patient (0.24%). There was no instance of retrograde ejaculation in male patients, and most complications had no long-term sequelae. CONCLUSIONS: This report presents a detailed analysis of complications related to anterior lumbar surgery. Although the incidence of complications appears low considering the magnitude of the procedure, surgeons should be aware of these potential complications and their management.

Mini-transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion augmented by percutaneous pedicle screw fixation: a comparison of surgical outcomes in adult low-grade isthmic spondylolisthesis.

STUDY DESIGN: Retrospective clinical data analysis. OBJECTIVE: To compare clinical results with radiologic results of 2 fusion techniques for adult low-grade isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: There is clear evidence that lumbar interbody fusion using anterior and posterior approaches provides a high fusion rate, good sagittal alignment, and good clinical outcomes. However, there are no recent studies that compare these 2 fusion techniques. METHODS: Between March 2004 and December 2004, 48 patients underwent instrumented mini-anterior lumbar interbody fusion (ALIF) and 46 underwent instrumented mini-transforaminal lumbar interbody fusion (TLIF). The mean follow-up periods were 32.6 and 29.7 months, respectively. RESULTS: The mean visual analog scale (VAS) scores for back and leg pain decreased, respectively, from 7.7 and 7.5 to 2.9 and 2.7 in the ALIF group and from 7.0 and 6.3 to 2.3 and 2.2 in the TLIF group. The mean Oswestry disability index (ODI) scores improved from 51.4% to 23.2% in the ALIF group and from 52% to 14.4% in the TLIF group. In both groups, the VAS and ODI scores significantly changed preoperatively to postoperatively (P<0.001). However, statistical analysis showed no significant difference in postoperative VAS/ODI scores between groups. Radiologic evidence of fusion was noted in 95.8% and 92.3% of the patients in the ALIF group and the TLIF group, respectively. In both the groups, changes in the disc height, segmental lordosis, degree of listhesis, and whole lumbar lordosis (WL) between the preoperative and postoperative periods were significant except for WL in the TLIF group. The amount of change between preoperative and postoperative disc height, segmental lordosis, and WL demonstrated significant intergroup differences (P<0.05). CONCLUSIONS: The mini-ALIF group demonstrated key radiographic advantages compared with the mini-TLIF group for adult low-grade isthmic spondylolisthesis. However, clinical and functional outcomes did not demonstrate significant differences between groups.

Anterior revision of a dislocated ProDisc prosthesis at the L4-5 level.

STUDY DESIGN: A case report describing our experience with anterior revision surgery for a dislocated ProDisc artificial disc at the L4-5 level, 2.5 years after the initial surgery. OBJECTIVE: To highlight the difficulties and risks associated with the use of a repeat anterior approach for the revision of a ProDisc that has failed at the L4-5 level. SUMMARY OF BACKGROUND DATA: As the ProDisc has a central vertical keel, more intensive vascular mobilization is required to remove the dislocated implant during surgery than that required in patients who must undergo a revision of the SB-Charité disc. To our knowledge, no prior report addresses whether the anterior removal of a ProDisc at the L4-5 level is possible in patients with severe retroperitoneal fibrosis. METHODS: We describe our surgical experience with the anterior revision of a lumbar ProDisc that failed at the L4-5 level. Revision surgery (anterior lumbar interbody fusion with percutaneous pedicle screw fixation) was performed 2.5 years after the initial surgery because of the anterior dislocation of the artificial disc after the patient had engaged in heavy lifting. The operation was performed with a repeat retroperitoneal approach. The multiple venous injuries that occurred intraoperatively were well controlled with a 5/0 polypropylene (Prolene) suture, but the patient lost a significant amount of blood (3800 mL) during surgery. RESULTS: The patient recovered from surgery without sequelae, and her preoperative symptoms resolved. CONCLUSIONS: A ProDisc revision case at L4-5 level must be attempted with preparation of available venous balloon catheter for emergent bleeding control, cell saver, pulse oxymeter on great toe, and ureteral catheter. In our opinion, usage of adhesion barrier material should be considered in anterior lumbar surgery to make revision exposure easier and safer.

Salvage Anterior Lumbar Interbody Fusion for Pseudoarthrosis After Posterior or Transforaminal Lumbar Interbody Fusion: A Review of 10 Patients.

BACKGROUND: After interbody cage implantation for posterior or transforaminal lumbar interbody fusion (PLIF or TLIF) spinal fusion surgery, pseudoarthrosis can develop. However, there are several shortcomings of the posterior approach if the interbody cage requires removal. Therefore, an anterior approach may be useful. METHODS: We reviewed salvage anterior lumbar interbody fusion (ALIF) for pseudoarthrosis after PLIF or TLIF performed from December 2006 to December 2016. A total of 10 patients met inclusion criteria for the study. All preoperative and postoperative clinical and radiologic parameters were recorded. RESULTS: Salvage ALIF resulted in improvements in clinical and radiologic outcomes in all cases. In 9 cases, the previously inserted cage was successfully removed. In 1 case, only 1 of the 2 previously inserted cages could be removed, as the previously inserted cage exhibited a high subsidence and remained in a diagonal position in the vertebral body. No serious complications occurred in all cases. Bone fusion was successful in all cases. CONCLUSIONS: ALIF is useful for salvage surgery to treat failed PLIF or TLIF. The advantages of salvage ALIF include improvements in clinical and radiologic outcomes and a low complication rate after surgery. To successfully remove a previously inserted cage, the vascular window of the anterior index level and the degree of subsidence of the cage should be well characterized through preoperative radiologic imaging.

Computed tomography-guided percutaneous facet screw fixation in the lumbar spine. Technical note.

The authors describe a new minimally invasive technique for posterior supplementation using percutaneous translaminar facet screw (TFS) fixation with computed tomography (CT) guidance. Oblique axial images were used to determine facet screw fixation sites. After the induction of local anesthesia and conscious sedation, a guide pin was inserted and guided with a laser mounted on the CT gantry. Cannulated TFSs were placed via a percutaneous approach. From December 2002 to August 2003, 18 patients underwent CT-guided TFS. In 17 of these patients this procedure was supplementary to anterior lumbar interbody fusion, which had been performed several days earlier; in the remaining patient, CT-guided TFS fixation was undertaken as the primary therapy. Twelve patients had painful degenerative disc disease or unstable degenerative spondylolisthesis, three had infections, and three had deformities. All screws were inserted accurately and there were no complications. This new minimally invasive surgical technique may offer an alternative to pedicle screw fixation as a method of posterior supplementation.

Lymphocele formation after anterior lumbar interbody fusion at L4-5. Case report.

In this report, the authors present the case of patient with a lymphocele in the retroperitoneal area following anterior lumbar interbody fusion at L4-5. A lymphocele is a rare complication of spinal operations, especially lower lumbar spinal surgeries. The authors discuss this complicating factor and describe its features and treatments.

Watertight Sealing Without Lumbar Drainage for Incidental Ventral Dural Defect in Transthoracic Spine Surgery: A Retrospective Review of 53 Cases.

STUDY DESIGN: A retrospective review. OBJECTIVES: To evaluate the therapeutic efficacy of the triple layer closure technique to establish watertight sealing without diversion of lumbar drainage, in preventing persistent incidental subarachnoid-pleural fistula and other neurological complications related to excessive drainage of cerebrospinal fluid (CSF) after dural defect in transthoracic ossified posterior longitudinal ligament (OPLL) surgery. SUMMARY OF BACKGROUND DATA: CSF leakage into the pleural cavity leads to unfavorable conditions for natural healing of incidental durotomy due to the negative pressure environment of the pleural space and lack of wound healing around the bony cavity near the decompressed spinal cord. This often leads to a persistent incidental subarachnoid-pleural fistula. In addition, diversion of lumbar drainage may lead to excessive CSF drainage resulting in intracranial hypotension. To avoid this, we studied the efficacy of a modified sealing method to establish a more watertight covering at the ventral dural defect without lumbar CSF drainage. METHODS: Fifty-three patients who had CSF leakage from the ventral aspect of the spinal cord during transthoracic spine surgery for thoracic OPLL between 2004 and 2013 were retrospectively reviewed. Patients were divided into 2 groups: a conventional group (group A) and a triple layer closure group (group B). In group A (n=33 patients), the dural defect was covered with fibrin glue (Beriplast P) mixed with gelfoam (Spongostan Standard) with subsequent subarachnoid lumbar drainage. In group B (n=20 patients), the dural defect was sealed using the triple layer technique with 2 layers of fibrin glue and gelatin sponge plus a third layer of synthetic hydrogel (Duraseal, Dural Sealant System) without subsequent subarachnoid lumbar drainage. Both groups had chest tubes that drained through an underwater seal. Clinical data including duration and total amount of drainage (chest tube and lumbar drainage), related complications, and duration of hospital stay were compared between the 2 groups. RESULTS: Compared with the patients in group A, group B had a significantly smaller total volume of drainage and shorter chest tube drainage time (P<0.05) during their hospital stay. In group A, complications occurred in 6 cases (18.2%), including 3 cases of intracranial hypotension combined with transient mental status alteration, postural headache, and dizziness, 1 case of regional atelectasis with pneumonia, and 2 cases of revision thoracotomy. Revision thoracotomy was performed to treat persistent subarachnoid-pleural fistula due to significant and prolonged CSF leakage. In group B, there were no complications and no revision thoracotomy was needed. The mean duration of hospital stay was shorter in group B (15.6 d) compared with group A (22.4 d). CONCLUSIONS: The established watertight closure of the dural defect using the triple layer sealing method without lumbar drainage was more effective and safe.

An evaluation of vascular anatomy for minilaparotomic anterior L4-5 procedures.

OBJECT: The complexity of the vascular anatomy pertinent to the L4-5 intervertebral disc space has led to difficulties when performing the anterior approach to the lumbar spine. The purpose of the present study was to evaluate the variations of the great vessels to match the imaging-documented axial anatomy with the surgical exposure. METHODS: The authors analyzed data obtained in 223 patients who had undergone mini-open anterior lumbar surgery involving the L4-5 disc. The preoperative magnetic resonance images or computed tomography scans were evaluated by examiners blinded to the surgical approach to determine the vascular configuration. All complications of the procedures were described. Two major variations of the vascular configuration were delineated according to the location of the bifurcation of the inferior vena cava. On images showing the lower margin of the L-4 vertebra, the anatomy in 182 patients (81%) was classified as Type A because the inferior vena cava (IVC) was not bifurcated; in 38 patients (17%) it was classified as Type B because the IVC was bifurcated. Type A could be subdivided into Types A1 and A2 according to whether the aorta was bifurcated (A2) or not (A1) on the same image. The surgical exposure used was above the bifurcations (in Type A) and below the bifurcations (in Type B). The major complications were three venous injuries, and the leading complication was sympathetic dysfunction in 14 patients, which in most cases resolved spontaneously. CONCLUSIONS: Careful preoperative evaluation of the vascular anatomy is essential to conducting successful anterior lumbar surgery. The determination of an appropriate approach can contribute to a reduction of unnecessary vascular retraction and a consequent decrease in vascular complications.

Revision surgery of the lumbar spine: anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation.

OBJECT: The aim of this study was to evaluate the efficacy of anterior lumbar interbody fusion (ALIF) augmented by percutaneous pedicle screw fixation (PSF) for revision surgery in the lumbar spine and to determine the prognostic factors affecting surgical outcomes. METHODS: The population included 54 consecutively treated patients in whom revision surgery involving ALIF with PSF was performed between 2001 and 2004. There were 22 men and 32 women, whose mean age was 59.5 years (range 25-78 years). The diagnoses prior to revision ALIF were as follows: degenerative disc disease in 25 patients, instability/spondylolisthesis in 15, recurrent disc herniation in seven, and pseudarthrosis in seven. The mean follow-up period was 24 months (range 12-52 months). The mean visual analog scale score for back and leg pain decreased, respectively, from 7.8 to 2.3 and 8.0 to 2.3 (p < 0.001). The mean Oswestry Disability Index score improved from 70 to 25% (p < 0.001). Radiological evidence of fusion was noted in 52 of 54 patients. The mean preoperative segmental lordosis, whole lumbar lordosis, and sacral tilt were 15.2, 35.5, and 28.3 degrees, respectively; these values were significantly increased to 20.4, 40.7, and 31.4degrees, respectively, after revision surgery (p < 0.001). The increase in sacral tilt was positively correlated with improvement in back pain (p = 0.028) and functional status (p = 0.025). CONCLUSIONS: The results demonstrate that ALIF followed by PSF can be an effective alternative in revision surgery of the lumbosacral spine in selected cases. Not only can solid fusion be achieved, sagittal alignment can also be restored in the majority of patients.

Salvage Percutaneous Vertebral Augmentation Using Polymethyl Methacrylate in Patients with Failed Interbody Fusion.

BACKGROUND: Percutaneous vertebral augmentation with cement is used as a salvage procedure for failed instrumentation. Few studies have reported the use of this procedure for failed anterior lumbar fusion in elderly patients with osteoporosis and other complicated diseases who have undergone a previous major operation. METHODS: Between January 2007 and December 2015, the clinical and radiographic results of 8 patients with osteoporosis who showed subsidence and migration of the implant after an initial operation were examined. After the development of implant failure, the patients underwent vertebral augmentation with polymethyl methacrylate. RESULTS: Mean patient age was 73.4 years (range, 67-78 years), and mean bone mineral density was -2.96 (range, -2.1 to -3.8). The mean radiologic follow-up period between augmentation and the last follow-up examination was 16 months (range, 3-38 months). Although the subjective clinical outcome was not satisfying to the patients, no loss of correction, fractures, or screw loosening occurred during the follow-up period. CONCLUSIONS: The injection of cement around the instrument might help to stabilize it by providing strength to the axis and preventing further loosening. This salvage procedure could be an alternative in the management of cases with failed interbody fusion.

Iliac artery perforation following lumbar discectomy with microsurgical carbon dioxide laser: a report of a rare case and discussion on the treatment.

STUDY DESIGN: Case report. OBJECTIVE: We present a rare complication of iliac artery perforation during lumbar disc surgery using a microscope-attached carbon dioxide laser system. SUMMARY OF BACKGROUND DATA: Since 1991, the authors have used a carbon dioxide laser to ablate disc fragment and osteophyte during lumbar microdiscectomy as a safe and convenient alternative to the scalpel and rongeur. We report the first case of a major vascular injury due to carbon dioxide laser. METHODS: A 42-year-old female patient underwent a right L5-S1 microdiscectomy for paramedian disc herniation. During the discectomy, the carbon dioxide laser was operated in continuous mode and irradiated anteriorly to ablate the intervertebral disc. High-energy (20 W) laser radiation caused perforation of a major vessel. RESULTS: Emergent laparotomy was performed, and a right iliac artery injury was discovered and successfully repaired by general and vascular surgeons. The patient was discharged home without sequelae after 10 days. CONCLUSION: Lasers are used in many different medical fields and offer unique advantages. However, the physical capabilities of a laser should be fully recognized to avoid complication. In this case, prompt diagnosis and emergent laparotomy salvaged the laser-induced arterial injury.