Comparison of Complications of Anterolateral and Lateral TransPsoatic Retroperitoneal Approaches to the Th12-L5 Intervertebral Disks. Experience with 208 Patients

Abstract

Introduction Anterior lumbar interbody fusion using supportive cage is a common surgical method for treating degenerative lumbar spinal diseases. Improved surgical techniques and better results have led to renewed interest in this procedure and to the development of new lateral transPsoatic minimally invasive access to the lumbar disks. The aim of this study was to compare the rate of complications during traditional anterolateral and new lateral transPsoatic retroperitoneal approaches to the intervertebral disks (IVD) at levels Th12-L5. Materials and Methods We reviewed all cases of the IVD anterolateral and lateral surgery at level Th12-L5, treated at the Department of Neurosurgery from January 1996 to June 2011. The ALIF (Anterior Lumbar Interbody Fusion) group consisted of 120 patients: 53 women and 67 men, average age 44 years, range 17 to 76 years; and the XLIF (Extreme Lateral Interbody Fusion) group consisted of 88 patients: 50 women and 38 men, average age 51 years, range 17 to 74 years. They suffered from low back pain (LBP) and usually radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography, and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. The preoperative diagnosis of ALIF group was degenerative disk disease at 39 levels, failed back surgery syndrome (FBSS) at 27, spondylolisthesis at 27, and posttraumatic disk injury at 35 levels. The preoperative diagnosis of XLIF group was DDD at 39, FBSS at 22, spondylolisthesis at 17, retrolisthesis at 5, and posttraumatic disk injury at 9 levels. The whole surgery, including surgical approach in the lateral decubitus position, was performed by an experienced neurosurgical team. The surgical steps in the minimally invasive anterolateral retroperitoneal approach and lateral retroperitoneal transPsoatic approach from the left side to disks Th12-L5 are described. Intraoperatively during XLIF procedure, the surgeon identified the lumbar nerve roots with stimulator to prevent their injury. All surgical intraoperative and postoperative complications directly related to the spinal surgery were documented. Both study groups were compared to each other. Results In both the groups, we had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, injury of ureter or kidney, ileus, retrograde ejaculation, or sterility. In ALIF group, intra- and postoperative minor complications were found in 35 patients (29%), the main intraoperative complication was the necessity to perform sympathectomy of lumbar sympathetic chain to obtain wide access to the disks in 19 patients (16%). For all of these patients with symptoms of sympathectomy the thermography was done as a sensitive test. The main postoperative complications were numbness of left anterolateral thigh or groin or transient pain of left groin in 16 patients (13%). In XLIF group, we had partial and transient injury of L5 nerve root (just the first patient) during implant insertion at level L4/5 (one patient, 1%), without using an intraoperative neuromonitoring (IOM). Since this major complication, we started using IOM strictly and didnát have more nerve injuries. In XLIF group, intra- and postoperative minor complications were found in 20 patients (23%), mainly transient pain of left groin in 11 patients and sympathectomy in 4 patients. At follow-up, we found no hardware failure on X-ray (implant displacement). Total 198 patients were satisfied with the surgery and reported improvement, 10 patients were neither improved nor worsened. Conclusion Rate of minor complications was similar in both groups, in ALIF group 29% and in XLIF group 23% of treated patients. Only one major complication, nerve root injury, was due to underestimation of XLIF procedure in the beginning. Retroperitoneal access and surgery at levels Th12-L5 disk space is a safe procedure when performed by a knowledgeable and experienced spine team. IOM during XLIF surgery is fully recommended. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Crock HV. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique. Clinical Orthopaedics 1982;165:157–163 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. 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