Reoperative Anterior Lumbar Spine Access is Feasible and Safe

Abstract

During the past two decades, the number of anterior lumbar spine reconstructions has increased significantly, as has the need for revisions and treatment of adjacent levels. We sought to determine the feasibility of reoperative anterior lumbar spine exposure. We performed a retrospective analysis of patients who had undergone repeat anterior extraperitoneal exposure of the lumbar spine from January 2009 to March 2021. Cases were excluded if reoperation had occurred within 1 month of the index procedure or if the reoperation had used a lateral approach. The demographic data and details on the operative procedure were analyzed. During the study period, 6130 procedures for anterior, oblique, or lateral exposure of the lumbar spine were performed. Within this cohort, 137 anterior reoperations were performed on 135 patients (mean age, 55.7 years; range, 19-83 years). The mean body mass index was 25.7 kg/m2 (range, 17-43 kg/m2). Most reoperations were remote from the index disc level (61%). The main indications for reoperation were adjacent level disease (n = 84), failed artificial disk repair (n = 25), and nonunion (n = 16). The approach was via the contralateral retroperitoneal space in 74, ipsilateral in 61, both sides in 1, and retro- and transperitoneal in 1. The median estimated blood loss for the 61 procedures performed without concomitant posterior reconstruction was 150 mL (range, 10-2050 mL). The procedure was aborted in seven cases (5%) because of the intraoperative anatomic findings. The levels successfully treated were L2-L3 in 16, L3-L4 in 26, L4-L5 in 30, L5-S1 in 88, and L6-S1 in 1. Artificial disk repair was performed at 33 levels and fusions at 128 levels. Two minor ureteral injuries occurred. Twenty venous injuries (15%) were primarily repaired. One patient required a venous stent for iatrogenic stenosis. Two internal iliac artery injuries were treated with ligation or repair. No patient died. Reoperative anterior spine exposure was successful in 95% of cases with relatively low morbidity and no mortality. Primary exposure of the L5-S1 level should be performed in the right retroperitoneal space to preserve the left side for adjacent level exposure. Ureteral catheters are recommended to assist in identifying the ureters when ipsilateral retroperitoneal exposure is required.