Anterior Lumbar Surgery Research Articles

Anterior lumbar interbody surgery for spondylosis results from a classically-trained neurosurgeon

Anterior lumbar surgery for degenerative disc disease (DDD) is a relatively novel technique that can prevent damage to posterior osseous, muscular and ligamentous spinal elements. This study reports the outcomes and complications in 286 patients who underwent fusion – with artificial disc implants or combined fusion and artificial disc implants – by a single-operator neurosurgeon, with up to 24months of follow-up. The visual analogue scale (VAS), Oswestry Disability Index (ODI), Short Form 36 (SF36) and prospective log of adverse events were used to assess the clinical outcome. Radiographic assessments of implant position and bony fusion were analysed. Intraoperative and postoperative complications were also recorded. Irrespective of pre-surgical symptoms (back pain alone or back and leg pain combined), workers’ compensation status and type of surgical implant, clinically significant improvements in VAS, ODI and SF36 were primarily observed at 3 and/or 6month follow-up, and improvements were maintained at 24months after surgery. A 94% fusion rate was obtained; the overall complication was 9.8% which included 3.5% with vascular complications. The anterior lumbar approach can be used for treating DDD for both back pain and back and leg pain with low complication rates. With appropriate training, single-operator neurosurgeons can safely perform these surgeries.

Access-related complications in anterior lumbar surgery in patients over 60 years of age

The anterior approach is widely used for access to the lumbar spine in the setting of adult deformity either as a stand-alone procedure or in combined anterior-posterior procedures. Access-related complication rates have so far not been reported in an elderly patient population, in which it has been suggested that anterior lumbar surgery is indicated with caution. Here, the complication rates in patients over 60 years of age are reported. A retrospective chart review in a consecutive series of 31 patients over 60 years of age and in which a retroperitoneal access to the lumbar spine was performed. All charts including anaesthetic charts were reviewed and the patients' demographics, exact surgical procedure, comorbidities, and potential risk factors, as well as intraoperative and vascular complications noted. Patients who had revision anterior surgery, anterior surgery for tumour resection, trauma or infection were excluded. The average age of patients was 64.9 years, ranging 60-81. Eighteen patients were female and 13 male. The average body mass index was 26.7 ranging 18.5-44.0. The indications for surgery were degenerative scoliosis (12 patients), degenerative spondylosis (7 patients), degenerative spondylolisthesis (5 patients), iatrogenic spondylolisthesis following prior posterior decompression (5 patients), and pseudarthrosis following posterolateral instrumented fusion (2 patients). In 10 patients, a single-level anterior lumbar interbody fusion (ALIF) was carried out (1 L3/4, 5 L4/5, 4 L5/S1) and in 11 patients ALIF was performed on two levels (1 L2-4, 1 L3-5, 9 L4-S1). In three patients, 3 levels from L3 to S1 were approached and in seven patients 4 levels from L2 to S1. Patients with three- and four-level anterior lumbar surgery had higher blood loss than two- and one-level surgery (616 ± 340 vs 439 ± 238, p = 0.036). The overall complication rate was 29% (9/31), which included four vascular injuries and one pulmonary embolism. The vascular complication rate was 13% (4/31) with two arterial and two venous injuries requiring repair. No major blood loss over 2,000 ml occurred. Anterior lumbar surgery in an elderly population does not necessarily have higher overall complication rates than in a younger population. The risk of vascular injury requiring repair was higher, but has not resulted in major blood loss and the procedure therefore can be carried out safely. The overall complication rate and blood loss compare favourably to complication rates in posterior adult deformity procedures.

Outcomes and complications of the midline anterior approach 3 years after lumbar spine surgery.

Objective. The purpose of this study was to evaluate a new questionnaire to assess outcomes related to the midline anterior lumbar approach and to identify risk factors for negative patient responses. Methods. A retrospective review of 58 patients who underwent anterior lumbar surgery at a single institution for either degenerative disc disease or spondylolisthesis in 2009 was performed. The outcome measures included our newly developed Anterior Lumbar Surgery Questionnaire (ALSQ), ODI, and EQ-5D. Results. There were 58 patients available for followup, 27 women and 31 men. The average age at surgery was 50.8 years, with an average followup of 2.92 years. The average change in ODI was 34.94 (22.7) and EQ-5D was 0.28 (0.29). The rate of complications with the anterior approach was 10.3% and there was one male patient (3.2%) with retrograde ejaculation. Determination of the effectiveness of the new ALSQ revealed that it significantly correlated to the EQ-5D and ODI (P < 0.05). Smoking was associated with a negative response on thirteen questions. BMP use was not associated with a negative response on any sexual function questions. Conclusions. Our new Anterior Lumbar Surgery Questionnaire determines patient perceived complications related to the midline anterior lumbar surgical approach.

Surgery-related complications and sequelae in management of tuberculosis of spine.

Study DesignMedical record-based survey.PurposeTo survey the overall incidence of the intra- and postoperative complications and sequelae, and to propose the preventive measures to reduce complications in the spinal tuberculosis surgery.Overview of LiteratureThere is no study focused on the surgery-related complications and sequelae, with some touching lightly on the clinical problems.MethodsThere were 901 patients in this study, including 92 paraplegics. One hundred eighty-six patients had no visible deformity, while those of 715 patients were visible. Six hundred fifty-nine patients had slight to moderate non-rigid kyphosis, and 56 had severe rigid kyphosis. Sixty-seven out of 92 paraplegics had slight to moderate non-rigid kyphosis, and 25 had severe kyphosis. There were 134 cervical and cervicodorsal lesions, 518 thoracic and thoracolumbar lesions, and 249 lumbar and lumbosacral lesions. Seven hundred sixty-four patients had primarily anterior surgeries, and 137 had posterior surgeries. Instrumentation surgery was combined in 174 patients.ResultsThere were intra- and postoperative complications: direct large vessel and neurological injuries (cord, roots, nerves), late thrombophlebitis, various thoracic cavity problems, esophagus and ureter injuries, peritoneum perforation, ileus, wound infections, stabilization failure, increase of deformity and late adjacent joint and bone problems. Thrombophlebitis and sympatheticolysis symptoms and signs in the lower limbs were the most common complications related with anterior lumbar and lumbosacral surgeries. Kyphosis increased in 31.5% of the non-instrumented anterior surgery cases (42% in children and 21% in adults).ConclusionsThe safe, effective and most familiar surgical procedure should be adopted to minimize complications and sequelae. Cosmetic spinal surgery should be withheld if functional improvement could not be expected.

Venous Air Embolism during Anterior Lumbar Surgery

ABSTRACT The use of transesophageal echocardiography (TEE) has improved the detection of venous air embolism (VAE), especially in the case of small VAE where clinical changes can be subtle and erroneously attributed to volume status or cardiac function. We present a case of VAE in a 62 years old female that occurred during anterior lumbar spine surgery that was diagnosed with the aid of TEE. As anterior lumbar spines surgery is traditionally not associated with VAE, we believe this is the first reported case of VAE in this type of procedure. How to cite this article Cho SJ, Bader SO, Heitz JW. Venous Air Embolism during Anterior Lumbar Surgery. J Perioper Echocardiogr 2013;1(1):30-32.

Posterior and Anterior Spinal Fusion for the Management of Deformities in Patients with Parkinson's Disease

Introduction. Spinal scoliosis and kyphosis in elderly people sometimes cause severe low back pain. Surgical methods such as osteotomy are useful for correcting the deformity. However, complications during and after surgery are associated with the osteotomy procedure. In particular, it is difficult to manage deformity correction surgery for patients with Parkinson's disease. Here, we present two cases of combined anterior and posterior surgery for deformity in patients with adult scoliosis and kyphosis due to Parkinson's disease. Case Presentation. Two 70-year-old women had spinal scoliosis and kyphosis due to Parkinson's disease. They had severe low back pain, and conservative treatment was not effective for the pain. Surgery was planned to correct the deformity in both patients. We performed combined posterior and anterior correction surgery. At first, posterior fusions were performed from T4 to the ilium using pedicle screws. Next, cages and autograft from the iliac crest were used in anterior lumbar surgery. The patients became symptom free after surgery. Bony fusion was observed 12 months after surgery. Conclusions. Combined posterior and anterior fusion surgery is effective for patients who show scoliosis and kyphosis deformity, and symptomatic low back pain due to Parkinson's disease.

Access related complications in anterior lumbar surgery performed by spinal surgeons

Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion (ALIF) and artificial disc replacement (ADR). Our aim was to study the exposure related complications for anterior lumbar spinal surgery performed by spinal surgeons. A retrospective review was performed for 304 consecutive patients who underwent anterior lumbar spinal surgery over 10 years (2001-2010) at our institution. Each patient's records were reviewed for patients' demographics, diagnosis, level(s) of surgery, procedure and complications related to access surgery. Patients undergoing anterior lumbar access for tumour resection, infection, trauma and revision surgeries were excluded. All patients underwent an anterior paramedian retroperitoneal approach from the left side. The mean age of patients was 43 years (10-73; 197 males, 107 females). Indications for surgery were degenerative disc disease (DDD 255), degenerative spondylolisthesis (23), scoliosis (18), iatrogenic spondylolisthesis (5) and pseudoarthrosis (3). The procedures performed were single level surgery--L5/S1 (n = 147), L4/5 (n = 62), L3/4 (n = 7); two levels--L4/5 and L5/S1 (n = 74), L3/4 and L4/5 (n = 4); three levels--L3/4, L4/5, L5/S1 (n = 5); four levels--L2/3, L3/4, L4/5, L5/S1 (n = 5). The operative procedures were single level ADR (n = 131), a single level ALIF (n = 87) with or without posterior fusion, two levels ALIF (n = 54), two levels ADR (n = 14), a combination of ADR/ALIF (n = 10), three levels ALIF (n = 1), three levels ADR/ALIF/ALIF (n = 1), ADR/ADR/ALIF (n = 2), four levels ALIF (n = 1) and finally 3 patients underwent a four level ADR/ADR/ALIF/ALIF. The overall complication rate was 61/304 (20 %). This included major complications (6.2 %)--venous injury requiring suture repair (n = 14, 4.6 %) and arterial injury (n = 5 [1.6 %], 3 repaired, 2 thrombolysed). Minor complications (13.8 %) included venous injury managed without repair (n = 5, 1.6 %), infection (n = 13, 4.3 %), incidental peritoneal opening (n = 12, 3.9 %), leg oedema (n = 2, 0.6 %) and others (n = 10, 3.3 %). We had no cases of retrograde ejaculation. We report a very thorough and critical review of our anterior lumbar access surgeries performed mostly for DDD and spondylolisthesis at L4/5 and L5/S1 levels. Vascular problems of any type (24/304, 7.8 %) were the most common complication during this approach. The incidence of major venous injury requiring repair was 14/304 (4.6 %) and arterial injury 5/304 (1.6 %). The requirement for a vascular surgeon with the vascular injury was 9/304 (3 %; 5 arterial injuries; 4 venous injuries). This also suggests that the majority of the major venous injuries were repaired by the spinal surgeon (10/14, 71 %). Our results are comparable to other studies and support the notion that anterior access surgery to the lumbar spine can be performed safely by spinal surgeons. With adequate training, spinal surgeons are capable of performing this approach without direct vascular support, but they should be available if required.

Variations of the Iliolumbar and Ascending Lumbar Veins

A cadaveric retrospective study. To verify the variation of tributaries draining into the iliac system at the lumbosacral junction. Special attention to vascular anatomy at the great venous bifurcation during anterior lumbar surgery is needed as more tributaries may increase the rate of operative bleeding. Although important, there have been very few detailed anatomic studies about variations of the ascending and iliolumbar veins. The latter tributary forms a horizontal system draining blood into the iliac vein. A total of 116 formaldehyde-preserved specimens (61 male and 55 female) were studied. All specimens were dissected and simply classified into patterns and subpatterns according to the similar or different tributaries and their entry points. There were 2 patterns of tributaries: symmetric and asymmetric. More variants were found in the asymmetric group. Each pattern comprising 58 specimens was further classified into 3 subpatterns according to their main tributary trunks. One to 3 tributaries may enter into any trunk of the iliac vein. The most common trunk was the common iliac vein seen in 75.9% of specimens. Draining into the external and internal veins was found in 21.6% and 2.6% of specimens, respectively. One common drainage of the ascending and iliolumbar veins on 1 or both sides was found in 0.9% and > 50% of specimens, respectively (right, 51.7%; left, 56%), whereas 2 or more tributaries were seen in < 50% of specimens (right, 47.4%; left, 43.1%). There was no significant statistical difference among sexes and body sides. Draining into the iliac system has a high frequency of variations through a number of tributaries and their entry points. The iliolumbar vein will mainly drain into the common iliac vein with frequently 2 or 3 tributaries, whereas drainage into the external iliac or the internal vein is less often observed.

Retrograde ejaculation following single-level anterior lumbar surgery with or without recombinant human bone morphogenetic protein–2 in 5 randomized controlled trials

The aim of this study was to determine the incidence and assess specific risk factors in the postoperative development of retrograde ejaculation (RE) in men treated for degenerative lumbar disc disease at the L4-5 or L5-S1 level with stand-alone anterior interbody implants with or without recombinant human bone morphogenetic protein-2 (rhBMP-2). Patients enrolled in 5 prospective, randomized, multicenter FDA-approved investigational device exemption studies were observed for a minimum of 2 years to assess the rate of RE. Five hundred eight men with symptomatic single-level lumbar degenerative disc disease with up to Grade 1 spondylolisthesis underwent anterior lumbar interbody surgery with stand-alone anterior implants at either L4-5 or L5-S1. All patient self-reported and physician-documented adverse events were recorded over the entire course of follow-up. In the investigational groups, 207 patients were treated with an open surgical procedure using dual paired constructs and rhBMP-2 on an absorbable collagen sponge. The control groups (n = 301) were treated with lumbar fusion cage implants and iliac crest autograft or a metal-on-metal disc arthroplasty device. Multivariate analyses of RE were performed to assess the influence of treatment (rhBMP-2), surgical approach, and treated level. Data were analyzed for each trial individually and for the data pooled from the 5 trials. Retrograde ejaculation occurred at the highest rates in the earliest clinical trial. Of the 146 men, 6 (4.1%) developed RE postoperatively. In subsequent studies, the rates of RE ranged from 0% to 2.1%. Combining the data from the 5 trials, RE was reported in 7 (3.4%) of the 207 patients who received the rhBMP-2 treatment compared with 5 (1.7%) of the 301 patients who received the autograft or lumbar disc treatment (p = 0.242, Fisher exact test). Cases of RE were reported in 7 (1.6%) of 445 patients who underwent a retroperitoneal spinal exposure; 5 RE cases were reported in 58 patients (8.6%) who underwent a transperitoneal approach. The difference in surgical approaches was significant (p = 0.007, Fisher exact test). There was no difference in the rate of RE based on the lumbar level exposed (p = 0.739). Multivariate analyses were consistent with the conclusions from Fisher exact tests. In the initial rhBMP-2 trial, after adjusting for effects of surgical approach and treated level, the difference in RE between the treatment groups (rhBMP-2 vs autograft or disc arthroplasty) was not significant (p = 0.177); however, the difference in RE between the retroperitoneal and transperitoneal approaches was significant (p = 0.029). In these 5 prospective randomized trials involving anterior lumbar interbody surgery, the use of rhBMP-2 was associated with a higher incidence of RE (3.4% vs 1.7%) but did not reach statistical significance. Based on surgical approach, the difference in rates of RE was statistically significant. This study reports on the outcomes of 5 prospective randomized FDA-approved investigational device exemption trials. Registration for studies became law in 2007. Four of these trials were completed before the law went into effect. The registration number for the lumbar disc arthroplasty trial is NCT00635843.

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution. This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20-80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision. Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction. Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.

Retrograde Ejaculation After Anterior Lumbar Spine Surgery

A retrospective cohort study. To compare the incidence of retrograde ejaculation (RE) after anterior lumbar spine surgery with disc replacement versus fusion with the use of recombinant human bone morphogenetic protein-2 (BMP). Anterior lumbar interbody fusion (ALIF) has become a popular choice for treating a number of pathologies, largely because it preserves the posterior paravertebral muscles and ligaments. Despite these advantages, the anterior approach is also associated with various complications, one of which is RE. A recent study has questioned whether the risk of RE is increased by the use of BMP in ALIF procedures rather than by the approach alone. We conducted a retrospective review of all male patients who received ALIF using BMP or artificial disc replacement (ADR) on at least the L5-S1 level between 2004 and 2011. Medical records were evaluated for the occurrence of RE, and patients were contacted via the phone to obtain current information. The incidence of RE was then compared between the 2 anterior lumbar surgery procedures. Of the 95 cases of anterior surgery including L5-S1, 54 patients underwent ALIF with BMP (56.8%) and 41 patients were treated with ADR (43.2%). Postoperative RE occurred in 4 of the 54 ALIF patients (7.4%) and in 4 of the 41 ADR patients (9.8%). The incidence of RE was not significantly different between groups (P = 0.7226). At latest follow-up, 1 ALIF and 1 ADR patient reported resolution of the RE. This study found that RE occurred at a similar rate in patients treated with ADR and ALIF with BMP. The overall rate of RE after retroperitoneal anterior lumbar surgery was higher than expected, which underscores the importance of counseling patients about this risk and specifically questioning patients about the symptoms of RE at postoperative visits.

Access-Related Complications in Anterior Lumbar Surgery Performed by Spinal Surgeons

Access-Related Complications in Anterior Lumbar Surgery Performed by Spinal Surgeons

The role of the vascular surgeon in anterior lumbar spine surgery

Objectives. Advances in spinal fusion techniques have led to an increase in the need for safe access to the lumbar spine anteriorly. The aim of this study is to examine the procedure-related complications of anterior lumbar inter-body fusion (ALIF) or anterior lumbar disc replacement (ALDR) when performed jointly by a vascular-surgeon and a neurosurgeon in a single centre. Methods. A retrospective cohort analysis was conducted for all patients who underwent ALIF or ALDR between 2004 and 2010. Operative notes were examined to identify any procedure-specific complications. In-hospital postoperative complications were recorded. Outpatients’ records were reviewed to record any late-onset postoperative complications. Results. A total of 121 patients (68 female and 53 males) were included. Mean age was 44 years (range of 25–76). Eighty patients (66%) had ALIF while 24 patients (20%) underwent ALDR. The remaining 17 patients (14%) had combined procedure for multilevel disease. In all patients, a transperitoneal approach was performed by vascular surgeon. The main indication (88%) for performing surgery was degenerative lumbar disc disease. No visceral or ‘major vascular’ complications were reported in any patients. Only three patients had ‘minor vascular’ injuries. The only significant postoperative complication was self-limiting paralytic ileus affecting 18 patients (14.8%). Hospital stay ranged from 4 to 9 days (median of 5 days).Conclusions. The anterior lumbar approach is not generally favoured by many neurosurgeons, despite its many advantages, due to the significant risk of vascular injuries as reported in the literature. This risk is especially acknowledged by the emerging generation of neurosurgeons with very little general surgical exposure during the training years. Adopting a combined vascular and neurosurgical approach has been reported to reduce the risk of vascular injury in anterior lumbar surgery acceptably low. This team approach provides an excellent opportunity to preserve some key ‘general’ surgical skills for neurosurgeons and ensure safe outcome for the patients.

Expert’s comment concerning Grand Rounds case entitled “The routine intra-operative use of pulse oximetry for monitoring can prevent severe thromboembolic complications in anterior surgery” (by M.A. König, Y. Leung, S. Jürgens, S. MacSweeney and B.M. Boszczyk)

Routine monitoring of left extremity circulation with pulse oximetry during anterior lumbar surgery may help diagnose left iliac artery thrombosis and will lead to quick treatment of this potentially catastrophic complication.

Polytetrafluoroethylene Membrane (Gore Preclude Vessel Guard) for Vessel Protection During Anterior Lumbar Surgery

The effects of implanting a polytetrafluoroethylene (PTFE) membrane (Gore Preclude Vessel Guard, WL Gore and Associates, Flagstaff, AZ) during anterior lumbar surgery were studied in a pig model. We investigated whether placement of a PTFE membrane between the great vessels and anterior surface of the lumbar spine would minimize adhesions. Anterior lumbar procedures continue to increase, as do revision operations. Anterior approaches remain challenging, however, because of the considerable risk of vascular injury. The risk is especially high with revision procedures because of the presence of adhesions that can hinder visualization and mobilization of vessels. Use of an anti-adhesion barrier may decrease the rate of vascular complications associated with revision surgery. Three spinal levels in 3 pigs were subjected to either discectomy, creation of a hole in the disc, or disc exposure only. In 5 of the 9 levels, a PTFE membrane was then implanted over the disc; the other 4 levels were controls. Spine segments were obtained 12 weeks later, and the tenacity of adhesions (scale of 0 to 4) and percentage of disc space covered by adhesions were assessed. The specimens were also studied histologically. Mean values for adhesion tenacity were 2.75 for control spinal levels and 0.4 for levels with a PTFE membrane (P=0.008). Mean values for adhesion coverage were 81% for control disc spaces and 15% for spaces with a PTFE membrane (P=0.008). Histologic studies showed minimal adhesions, lack of an inflammatory reaction, and vascularized connective tissue between PTFE membranes and the vena cava. In a pig model, implantation of a PTFE membrane during anterior lumbar surgery decreased the tenacity and amount of adhesions observed at necropsy. Studies of the efficacy and safety of the PTFE membrane in clinical anterior lumbar surgery are warranted.

Complications of Anterior Lumbar Surgery

The incidence of anterior lumbar surgery is increasing. Although adverse events are uncommon, several have been described. Complications can be categorized based on the time of occurrence (ie, intraoperative, postoperative), patient positioning, surgical exposure, and spinal procedure. Notable approach-related complications involve vascular, visceral, and neural structures. Abdominal complications have been reported. Clinically significant complications related to spinal decompression and reconstruction consist primarily of neurologic injuries and graft- and device-related problems. The rate of complications is higher in the setting of revision anterior surgery than with initial anterior lumbar surgery. A thorough understanding of the complications associated with anterior lumbar surgery will aid in prevention, recognition, and management of these rare problems. The assistance of a vascular, neurologic, or general surgeon may be helpful in avoiding or effectively managing complications.

Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery

BackgroundExposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported. This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order to prevent lumbar plexus injuries and to increase the possibility of safety in anterior approach lumbar surgery.MethodsTo study the applied anatomy related to the lumbar plexus of fifteen formaldehyde-preserved cadavers, Five sets of Virtual Human (VH) data set were prepared and used in the study. Three-dimensional (3D) computerized reconstructions of the lumbar plexus and their adjacent structures were conducted from the VH female data set.ResultsThe order of lumbar nerves is regular. From the anterior view, lumbar plexus nerves are arranged from medial at L5 to lateral at L2. From the lateral view, lumbar nerves are arranged from ventral at L2 to dorsal at L5. The angle of each nerve root exiting outward to the corresponding intervertebral foramen increases from L1 to L5. The lumbar plexus nerves are observed to be in close contact with transverse processes (TP). All parts of the lumbar plexus were located by sectional anatomy in the dorsal third of the psoas muscle. Thus, access to the psoas major muscle at the ventral 2/3 region can safely prevent nerve injuries. 3D reconstruction of the lumbar plexus based on VCH data can clearly show the relationships between the lumbar plexus and the blood vessels, vertebral body, kidney, and psoas muscle.ConclusionThe psoas muscle can be considered as a surgical landmark since incision at the ventral 2/3 of the region can prevent lumbar plexus injuries for procedures requiring exposure of the lateral anterior of the lumbar. The transverse process can be considered as a landmark and reference in surgical operations by its relative position to the lumbar plexus. 3D reconstructions of the lumbar plexus based on VCH data provide a virtual morphological basis for anterior lumbar surgery.

Complications Related to Anterior and Lateral Lumbar Surgery

Anterior and lateral approaches to the spine have an increasing role in addressing deformity, tumor, and degenerative conditions of the spine. When conducted by an experienced team and supportive care system, anterior and lateral approaches to the spine can be performed safely, with few complications and good to excellent patient outcomes and satisfaction. A thorough knowledge of vascular, neural, and visceral anatomy is essential in minimizing approach-related complications.

A clinical retrospective study of early complications associated with anterior approach thoracic and lumbar spine surgery for tuberculosis

A clinical retrospective study of early complications associated with anterior approach thoracic and lumbar spine surgery for tuberculosis

Retroperitoneal lymphocele after lumbar total disc replacement: a case report and review of literature

Background Retroperitoneal lymphoceles (RPLs) caused by injury to the lymphatics are commonly seen after pelvic lymphadenectomy, renal transplantation, and gynecologic tumor resection surgeries. Degenerative disc disease still remains the major cause of low-back pain. Anterior lumbar spinal procedures, such as anterior lumbar interbody fusion and anterior lumbar arthroplasty, have been increasingly performed for treatment of axial back pain. RPLs, as an approach-related complication, though infrequent, have been reported after anterior lumbar spinal surgery. We report a case of RPL after total disc replacement of the lumbar spine. To our knowledge, there has been no prior report of RPL after total disc replacement managed by percutaneous aspiration only. Methods A 49-year-old woman who underwent total disc replacement at the L4-5 level presented with a postoperative complication of RPL. The imaging findings, clinical course, and treatment are discussed, and a review of literature is presented. Results The patient presented with significant abdominal swelling and discomfort at 4 weeks after surgery without any signs or symptoms of infection. Investigations showed an RPL. She was treated by multiple aspirations under ultrasound guidance. At 12 months' follow-up, the patient had no further abdominal symptoms and had gone back to her routine activities and work with significant improvement in back pain. Conclusions RPL is an uncommon complication after anterior lumbar surgery and can be managed effectively if detected and diagnosed early. Although repeated aspiration is associated with high recurrence and infection, it is a safe and minimally invasive procedure to manage RPL.