78 © 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd
VIDEO OF ORTHOPAEDIC TECHNIQUE
Minimally Invasive Anterior Lumbar Interbody Fusion for Adjacent Segment Disease after Posterior Lumbar Fusion Jian-jun Ma, Shun-wu Fan, Feng-dong Zhao, Xiang-qian Fang Department of Orthopaedics, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou, China
Introduction osterior lumbar fusion is a popular technique for managing lumbar spine degenerative diseases including disc hernia, canal stenosis, scoliosis, spondylosis and degenerative spondylolisthesis. One of the commonest complications is adjacent segment disease (ASD). About 4.7% patients who have undergone lumbar fusion need revision surgery for ASD1. There are various revision procedures; they include anterior and posterior approaches. Due to the previous posterior procedure, the risks of a posterior revision approach are obviously high and include dural tear injury, nerve root injury, and secondary damage to posterior structures. Thus, a retroperitoneal approach to performing minimally invasive anterior lumbar interbody fusion (ALIF) would avoid all the risks mentioned above and might therefore be a better treatment option2,3.
P
Case Presentation and Surgical Technique 45-year-old female had undergone posterior lumbar interbody fusion at the L3–4 to L4–5 level and posterolateral fusion of the L5S1 level 6 months previously for degenerative disease of the lumbar spine in a local hospital with an initially satisfactory outcome. However, five months after this surgery, she had developed progressive low back pain with numbness and tingling throughout her right leg. Careful physical examination showed tenderness on the right side of the L5 spinous process. She had a positive Lasègue sign and straight leg raising test in the right leg. There was also decreased sensation over the lateral aspect of the leg, lateral malleolus and lateral aspect of the foot. Plantar flexion was weaker in her right foot than in her left. The ankle jerk was reduced on the right side. Routine laboratory investigations were normal. X-ray films revealed that L3–S1 had been fixed with pedicle screws and there were cages in the L3–4 and L4–5 interspaces. Osteolysis was noted around the pedicle screws in the S1 vertebral body. MRI
A
revealed disc herniation on the right side at the L5S1 level. Therefore, the preoperative diagnosis was disc herniation of L5S1 and ASD (L5S1). ALIF with an integrated titanium plate and a poly(ether-ether-ketone) (PEEK) cage (SynFix-LR, Synthes, Solothurn, Switzerland) was planned. To avoid vessel injury and identify an appropriate operating area, computed tomography angiography (CTA) of the abdominal aorta was performed preoperatively. After induction of general anesthesia, the patient was positioned supine on a table with a break at the level of the lumbar spine to exaggerate lumbosacral lordosis. A Pfannenstiel incision was made between the level of the umbilicus and symphysis pubis. The left side of the rectus sheath was dissected parallel to the midline and the left rectus abdominis was retracted laterally, after which the retroperitoneal space was entered by retracting all the periosteum to the right4. After the L5S1 level had been exposed and fluoroscopically verified, a SynFrame Retractor System (Synthes) was used to create a stable surgical field5. Before performing discectomy, the median sacral vessels were carefully ligatured or electrocoagulated. Then an adequate discectomy was performed6 and the nerve root was carefully decompressed. The adjacent vertebral endplates were scratched appropriately. After a trial cage had been tested, an appropriately sized cage with allograft was inserted into the intervertebral space. The cage was anchored by four diverging angle-stable locking screws into the adjacent vertebrae and its position was fluoroscopically confirmed. The operation time was 110 min with an estimated blood loss of 120 mL. The duration of hospitalization was 7 days. Discussion ith the improved PEEK cage integrated with a titanium locking plate and four angle-stable screws (SynFix-LR,
W
Address for correspondence Shun-wu Fan, MD, Department of Orthopaedics, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou, China 310016 Tel: 0086-013505819572; Fax: 0086-571-86044817; Email: [email protected]
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Orthopaedic Surgery 2014;6:78–79 • DOI: 10.1111/os.12095
79 Orthopaedic Surgery Volume 6 · Number 1 · February, 2014
Synthes), stand-alone ALIF can meet the biomechanical needs of lumbar fusion7,8. The improved cage is biomechanically superior to cages with separate plates9 and has a zero profile construct, which reduces the rates of vessel and visceral organ injury. The SynFrame Retractor System provides a more stable operative field and allows a smaller skin incision, reducing the risk of vessel and organ injury during the procedure5. A preoperative CTA of the abdominal aorta and careful handling of median sacral vessels increase the safety of this procedure. This technique facilitates more direct discectomy and more complete nerve decompression and involves a larger cage which results in higher fusion rates10. As a revision for ASD
Minimally Invasive Anterior Lumbar Interbody Fusion
after posterior lumbar fusion, ALIF offers direct anterior column support without disturbing the posterior scars around the dural sac and nerve roots. It also shortens operative time and thus expedites patient recovery.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video Clip S1. Mini-invasive anterior lumbar interbody fusion.
References 1. Lee JC, Kim Y, Soh JW, Shin BJ. Risk factors of adjacent segment disease requiring surgery following lumbar spinal fusion: comparison of PLIF and PLF. Spine, 2013, Dec 20. [Epub ahead of print]. 2. Fisher CG, Vaccaro AR, Whang PG, et al. Evidence-based recommendations for spine surgery. Spine, 2013, 38: E30–E37. 3. Mobbs RJ, Loganathan A, Yeung V, Rao PJ. Indications for anterior lumbar interbody fusion. Orthop Surg, 2013, 5: 153–163. 4. Wenger M, Vogt E, Markwalder TM. Double-segment Wilhelm Tell technique for anterior lumbar interbody fusion in unstable isthmic spondylolisthesis and adjacent segment discopathy. J Clin Neurosci, 2006, 13: 265–269. 5. Aebi M, Steffen T. Synframe: a preliminary report. Eur Spine J, 2000, 9 (Suppl. 1): S44–S50. 6. Aebi M, Parthasarathy S, Avadhani A, Rajasekaran S. Minimal invasive anterior lumbar interbody fusion (mini ALIF). Eur Spine J, 2010, 19: 335–336.
7. Schleicher P, Gerlach R, Schär B, et al. Biomechanical comparison of two different concepts for stand alone anterior lumbar interbody fusion. Eur Spine J, 2008, 17: 1757–1765. 8. Kang JD. Another complication associated with rhBMP-2? Spine J, 2011, 11: 517–519. 9. Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M. Stand-alone anterior versus anteroposterior lumbar interbody single-level fusion after a mean follow-up of 41 months. J Spinal Disord Tech, 2012, 25: 362–369. 10. Li J, Dumonski ML, Liu Q, et al. A multicenter study to evaluate the safety and efficacy of a stand-alone anterior carbon I/F Cage for anterior lumbar interbody fusion: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine, 2010, 35: E1564– E1570.
VIDEO OF ORTHOPAEDIC TECHNIQUE
Minimally Invasive Anterior Lumbar Interbody Fusion for Adjacent Segment Disease after Posterior Lumbar Fusion Jian-jun Ma, Shun-wu Fan, Feng-dong Zhao, Xiang-qian Fang Department of Orthopaedics, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou, China
Introduction osterior lumbar fusion is a popular technique for managing lumbar spine degenerative diseases including disc hernia, canal stenosis, scoliosis, spondylosis and degenerative spondylolisthesis. One of the commonest complications is adjacent segment disease (ASD). About 4.7% patients who have undergone lumbar fusion need revision surgery for ASD1. There are various revision procedures; they include anterior and posterior approaches. Due to the previous posterior procedure, the risks of a posterior revision approach are obviously high and include dural tear injury, nerve root injury, and secondary damage to posterior structures. Thus, a retroperitoneal approach to performing minimally invasive anterior lumbar interbody fusion (ALIF) would avoid all the risks mentioned above and might therefore be a better treatment option2,3.
P
Case Presentation and Surgical Technique 45-year-old female had undergone posterior lumbar interbody fusion at the L3–4 to L4–5 level and posterolateral fusion of the L5S1 level 6 months previously for degenerative disease of the lumbar spine in a local hospital with an initially satisfactory outcome. However, five months after this surgery, she had developed progressive low back pain with numbness and tingling throughout her right leg. Careful physical examination showed tenderness on the right side of the L5 spinous process. She had a positive Lasègue sign and straight leg raising test in the right leg. There was also decreased sensation over the lateral aspect of the leg, lateral malleolus and lateral aspect of the foot. Plantar flexion was weaker in her right foot than in her left. The ankle jerk was reduced on the right side. Routine laboratory investigations were normal. X-ray films revealed that L3–S1 had been fixed with pedicle screws and there were cages in the L3–4 and L4–5 interspaces. Osteolysis was noted around the pedicle screws in the S1 vertebral body. MRI
A
revealed disc herniation on the right side at the L5S1 level. Therefore, the preoperative diagnosis was disc herniation of L5S1 and ASD (L5S1). ALIF with an integrated titanium plate and a poly(ether-ether-ketone) (PEEK) cage (SynFix-LR, Synthes, Solothurn, Switzerland) was planned. To avoid vessel injury and identify an appropriate operating area, computed tomography angiography (CTA) of the abdominal aorta was performed preoperatively. After induction of general anesthesia, the patient was positioned supine on a table with a break at the level of the lumbar spine to exaggerate lumbosacral lordosis. A Pfannenstiel incision was made between the level of the umbilicus and symphysis pubis. The left side of the rectus sheath was dissected parallel to the midline and the left rectus abdominis was retracted laterally, after which the retroperitoneal space was entered by retracting all the periosteum to the right4. After the L5S1 level had been exposed and fluoroscopically verified, a SynFrame Retractor System (Synthes) was used to create a stable surgical field5. Before performing discectomy, the median sacral vessels were carefully ligatured or electrocoagulated. Then an adequate discectomy was performed6 and the nerve root was carefully decompressed. The adjacent vertebral endplates were scratched appropriately. After a trial cage had been tested, an appropriately sized cage with allograft was inserted into the intervertebral space. The cage was anchored by four diverging angle-stable locking screws into the adjacent vertebrae and its position was fluoroscopically confirmed. The operation time was 110 min with an estimated blood loss of 120 mL. The duration of hospitalization was 7 days. Discussion ith the improved PEEK cage integrated with a titanium locking plate and four angle-stable screws (SynFix-LR,
W
Address for correspondence Shun-wu Fan, MD, Department of Orthopaedics, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou, China 310016 Tel: 0086-013505819572; Fax: 0086-571-86044817; Email: [email protected]
bs_bs_banner
Orthopaedic Surgery 2014;6:78–79 • DOI: 10.1111/os.12095
79 Orthopaedic Surgery Volume 6 · Number 1 · February, 2014
Synthes), stand-alone ALIF can meet the biomechanical needs of lumbar fusion7,8. The improved cage is biomechanically superior to cages with separate plates9 and has a zero profile construct, which reduces the rates of vessel and visceral organ injury. The SynFrame Retractor System provides a more stable operative field and allows a smaller skin incision, reducing the risk of vessel and organ injury during the procedure5. A preoperative CTA of the abdominal aorta and careful handling of median sacral vessels increase the safety of this procedure. This technique facilitates more direct discectomy and more complete nerve decompression and involves a larger cage which results in higher fusion rates10. As a revision for ASD
Minimally Invasive Anterior Lumbar Interbody Fusion
after posterior lumbar fusion, ALIF offers direct anterior column support without disturbing the posterior scars around the dural sac and nerve roots. It also shortens operative time and thus expedites patient recovery.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video Clip S1. Mini-invasive anterior lumbar interbody fusion.
References 1. Lee JC, Kim Y, Soh JW, Shin BJ. Risk factors of adjacent segment disease requiring surgery following lumbar spinal fusion: comparison of PLIF and PLF. Spine, 2013, Dec 20. [Epub ahead of print]. 2. Fisher CG, Vaccaro AR, Whang PG, et al. Evidence-based recommendations for spine surgery. Spine, 2013, 38: E30–E37. 3. Mobbs RJ, Loganathan A, Yeung V, Rao PJ. Indications for anterior lumbar interbody fusion. Orthop Surg, 2013, 5: 153–163. 4. Wenger M, Vogt E, Markwalder TM. Double-segment Wilhelm Tell technique for anterior lumbar interbody fusion in unstable isthmic spondylolisthesis and adjacent segment discopathy. J Clin Neurosci, 2006, 13: 265–269. 5. Aebi M, Steffen T. Synframe: a preliminary report. Eur Spine J, 2000, 9 (Suppl. 1): S44–S50. 6. Aebi M, Parthasarathy S, Avadhani A, Rajasekaran S. Minimal invasive anterior lumbar interbody fusion (mini ALIF). Eur Spine J, 2010, 19: 335–336.
7. Schleicher P, Gerlach R, Schär B, et al. Biomechanical comparison of two different concepts for stand alone anterior lumbar interbody fusion. Eur Spine J, 2008, 17: 1757–1765. 8. Kang JD. Another complication associated with rhBMP-2? Spine J, 2011, 11: 517–519. 9. Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M. Stand-alone anterior versus anteroposterior lumbar interbody single-level fusion after a mean follow-up of 41 months. J Spinal Disord Tech, 2012, 25: 362–369. 10. Li J, Dumonski ML, Liu Q, et al. A multicenter study to evaluate the safety and efficacy of a stand-alone anterior carbon I/F Cage for anterior lumbar interbody fusion: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine, 2010, 35: E1564– E1570.
