Anterior Lumbar Surgery Research Articles

Changes in Abdominal Vascular Tension Associated With Various Leg Positions in the Anterior Lumbar Approach

A descriptive cadaveric study measuring arterial tension. Anterior lumbar surgery is technically challenging due to perioperative vascular complications. Many studies suggest approaches based on the anatomy of the abdominal vessel for safe vascular mobilization. However, the tension in the vascular structure is also important for adequate exposure of the target lesion. It has been established that the tension in the lumbar nerve at the root level can be changed by a straight leg raise test and that the structure of the vascular connection is similar to that of the neural connection. Consequently, a change in leg position could affect the tension of lumbosacral vessels. The purpose of this study was to evaluate the effect of leg position on the tension of lumbosacral vessels. We dissected 10 unembalmed cadavers using the method described by Gumbs et al, using the Synframe system to expose the abdominal artery and vein. The left iliac artery and the distal abdominal aorta were retracted to the right side at the L4-L5 disc level by a measuring retractor to which a strain gauge was attached. The tension was checked at various angles of the hip joint and the motions of the abdominal arteries were monitored in 4 unembalmed cadavers using a C-arm fluoroscope. The tension in the abdominal aorta at L4-L5 level was decreased by 2.9% to 21.8% in the hip-flexion position, and the motion of the arteries showed proximal displacement of the external iliac artery and the common iliac artery during the hip-flexed position and veins also showed the same pattern of displacement as artery. The results of this study would be useful for not only spinal surgery but also other vascular surgeries, particularly, in cases where patients with conditions such as atherosclerosis or stenosis.

Spinal reconstruction and bone morphogenetic proteins: Open questions

Abstract Spinal fusion is a proven surgical tool for the treatment of degenerative, traumatic, neoplastic, and infectious conditions of the spine. Traditional grafting techniques using autogenous bone graft or allograft have inherent drawbacks including varying pseudoarthrosis rates and well recognized bone graft harvest site complications. Bone morphogenetic proteins (BMPs) offer the exciting prospect of enhanced union rates equal to or greater than autograft and potentially eliminate graft harvest site complications. Many studies have clearly demonstrated the efficacy of BMP products for various applications in spine surgery. BMP has proven effective in achieving union in anterior and posterior lumbar surgery and recently in anterior cervical surgery. Despite the reported success, the universal adoption of BMP is tempered by high costs and lingering safety concerns with reported complications specific to BMP use including vertebral osteolysis, ectopic bone formation, radiculitis and cervical soft tissue swelling. Ongoing clinical and basic-science research is focused on clearly defining guidelines for BMP use in spine surgery and on developing more affordable BMP formulations with dosing that predictably results in spine fusion yet minimizes the possible side effect profile.

Anterior Exposure of the Lumbar Spine With and Without an “Access Surgeon”

Retrospective review To compare the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without an "access" surgeon. No data exist comparing the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without a vascular surgeon's assistance. A retrospective review was performed for 265 consecutive patients who underwent anterior lumbar spine surgery at our institution from 2003 to 2005. Each patient's records were reviewed for diagnosis, procedure, whether the surgical exposure was conducted by the spine surgeon (Spine) or with a vascular surgeon's assistance (Team), levels exposed, complications, and any lasting sequelae. The percentage of patients with at least 1 intraoperative complication was 8% and 12% for the Spine and Team cases, respectively. Two percent of the Spine patients experienced an intraoperative vascular complication compared with 7% of the Team cases. No intraoperative vascular complication occurred in the single-level Spine exposures. Four percent of the patients with single-level exposures with Team approaches sustained an intraoperative vascular complication. Eight percent of the multilevel Spine cases sustained an intraoperative vascular complication compared with 9% of the multilevel Team exposures. There were 14 vascular injuries appreciated intraoperatively in a total of 13 patients. These injuries were directly repaired in 10 patients without any residual sequelae. The rate of vascular complications was statistically higher for multiple-level exposures (9%) versus single-level exposure (3%; P = 0.0357). The rate of retrograde ejaculation was 6% in the Spine cases whereas it was 7% in the Team approach. Our results do not support the notion that the presence of an "access" surgeon will change the type and rate of complications. With adequate training and judgment, spine surgeons may safely perform such exposures, provided vascular surgical assistance is readily available.

Mini-invasive extraperitoneal approach for anterior lumbar surgery

To study a mini-invasive extraperitoneal approach to lumbar spine and discuss its exposure technique, complications and management. Anterior lumbar surgery was performed in 52 patients via the mini-invasive anterior extraperitoneal approach. Diagnoses included lumbar degenerative instability (n=23), discogenic lumbar pain (n=25), lumbosacral congenital deformity (n=2) and revision after posterior laminectomy & discectomy (n=2). The patients underwent anterior lumbar interbody fusion (n=32) and total disk replacement (n=20). The operated disks included L(4-5) and L5-S1. There were single level (n=47) and double level (n=5). Operation time, blood loss, perioperative complications, postoperative bed-leaving time, incision length, pain of abdomen incision and postoperative hospitalization duration were recorded in details. All cases were exposed clearly and no one needed to prolong incision or change operation for an insufficient exposure. Average operation time was 85 min, average blood loss 155 ml, average postoperative bed-leaving time 3 days and average incision length 6.5 cm. All cases felt very little pain of abdominal incision and postoperative hospitalization duration was 7-10 days. Perioperative complications included vena cava tear (n=1), peritoneum tear (n=2), postoperative abdominal distention (n=3) and postoperative fever (n=5). No retrograde ejaculation was found in all male cases. The technique of mini-invasive extraperitoneal approach to anterior lumbar has such multiple advantages as fewer complications, less trauma, excellent exposure to anterior vertebrae and disk and without destruction of posterior spinal component

Perioperative outcomes of anterior lumbar surgery in obese versus non-obese patients

Background context Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disc replacement but the impact of obesity on this procedure has not been determined. Purpose To assess the perioperative outcomes of anterior retroperitoneal lumbar surgery in obese versus non-obese patients. Study design/setting Prospective review of patients with anterior retroperitoneal lumbar disc procedures Patient sample Seventy-four patients with anterior retroperitoneal lumbar disc procedures performed were evaluated. Outcome measures Access-related parameters included tissue depth (skin-to-fascia and fascia-to-spine depths), length of incision, estimated blood loss during the anterior procedure, the duration of the anterior exposure, and the duration of the entire anterior procedure. Outcome measures included complications attributable to the anterior procedure, analgesic use, length of time to ambulation, and length of hospitalization. Methods Seventy-four anterior retroperitoneal lumbar disc procedures were prospectively analyzed. Patient age, sex, body mass index, comorbidities, diagnosis, and operative parameters were collected. Access-related parameters and outcome measures were compared between obese and non-obese patients. Obesity was defined as body mass index greater than or equal to 30. Results There were 35 males and 39 females. Mean age was 46.6 years. The main diagnosis (63.5%) was discogenic back pain. Forty-one (55%) patients were non-obese and 33 were obese. The two patient groups were comparable in terms of age, sex, diagnosis, mean number of anterior levels operated, and previous abdominal surgery (all p>.05). In obese patients, there were two iliac vein lacerations (major complication rate, 6.1%), one superficial infection, and one urinary tract infection (minor complication rate, 6.1%). In non-obese patients, there were two iliac vein lacerations, one intestinal serosal tear (major complication rate, 7.3%), and two urinary tract infections (minor complication rate, 4.9%). There was no significant difference in the complication rates between obese and non-obese patients (p=.6). Obese patients have significantly longer duration of anterior exposure, duration of entire anterior surgery, longer length of anterior incision, and more depth from skin to fascia and from fascia to spine compared with non-obese patients. However, obesity does not affect blood loss, analgesic use, length of time to ambulation, and length of hospitalization. Conclusion Perioperative outcomes in obese and non-obese patients were comparable and obesity is not related to an increased risk of morbidity in anterior lumbar surgery.

Lymphocoele: a rare and little known complication of anterior lumbar surgery

Lymphocoele is a rare and little known complication with only a handful of reports available. We report two cases of lymphocoele after anterior lumbar surgery that have occurred in two different centres and discuss diagnosis and management options. The first case is that of a 53-year-old male patient undergoing two level anterior lumbar interbody fusion (ALIF) for disabling back pain due to disc degeneration in the context of an old spondylodiscitis. He developed a large fluid mass postoperatively. Fluid levels of creatinin were low and intravenous urography ruled out a urinoma suggesting the diagnosis of a lymphocoele. Following two unsuccessful drainage attempts he underwent a laparoscopic marsupialization. The second case was that of a 32-year-old female patient developing a large fluid mass following a L5 corpectomy for a burst fracture. She was treated successfully with insertion of a vacuum drain during 7 days. Lymphocoele is a rare complication but should be suspected if fluid collects postoperatively following anterior lumbar spine procedures. Chemical analysis of the fluid can help in diagnosis. Modern treatment consists of laparoscopic marsupialization. Lymph vessel anatomy should be borne in mind while exposing the anterior lumbar spine.

Actin-Free Gc-Globulin after Minimal Access and Conventional Anterior Lumbar Surgery

Minimally invasive total knee or hip replacement has been increasingly adopted in recent years. However, literature indicates that minimally invasive joint arthroplasty may not always reduce pain or tissue trauma. We hypothesized that the tissue damage would be reduced in minimal access surgery (MAS) than the conventional open surgery (OS) for anterior lumbar disorders through quantifying measurement of serum actin-free Gc-globulin (Af-Gc), myoglobin (MG), and total creatine kinase (CK). This prospective study enrolled 23 patients, including 10 who underwent MAS and thirteen who underwent conventional OS. Blood samples for Af-Gc, MG, and CK were taken simultaneously before surgery and then at intervals of 12, 24, 48, 72, 120, and 168 h thereafter. All serum level changes in Af-Gc, MG, and CK were significantly lower in the MAS than in the OS group. A significant negative correlation was noted between changes in Af-Gc and MG levels (P = 0.012), and a significant positive correlation was noted between changes in CK and MG levels (P < 0.001). However, at 12 h postop, CK level was transiently higher in MAS group than the OS group. The changes of Af-Gc, MG, and CK levels indicate that MAS is less tissue invasive than OS. Further, Af-Gc proved to be a more sensitive marker than MG or CK in response to surgical trauma. The transiently higher CK level at 12 h postop in MAS patients may indicate that a more soft tissue manipulation is required in MAS than the OS patients for the initial surgical approach.

Clinical anatomy study of autonomic nerve with respective to the anterior approach lumbar surgery

Male genital dysfunction was recognized as a complication following anterior approach lumbar surgery. Disruption of efferent sympathetic pathways such as the abdominal aortic plexus (AAP) and superior hypogastric plexus (SHP) which lied pre-abdominal aorta and iliac artery had been thought as the main reason. Though there were some clinical reports of retrograde ejaculation, the applied anatomic study of the autonomic nerve anterior to the lumbar was little. The purpose was to find out a lumbar surgery approach which was ejaculation preservation through the detailed study of the anatomy and histology observation of the autonomic nerve anterior to the lumbar vertebrae. The lumbar region of ten male cadavers was dissected and analyzed. We investigated the relationship between the peritoneum and abdominal aorta, iliac artery and sacral promontory fascia, as well as the trend and distribution of the autonomic nerve and SHP anterior to the L5-S1. We also observed the distribution of autonomic nerve at retroperitoneum through hematoxylin and eosin (HE)-stained tissues pre-aorta, para-aorta, and pre-vertebrae sacrales. Superior hypogastric plexus, which deviated to left, located in a triangle formed by the common iliac arteries and its bilateral branches, its truck sited anterior to the lumbarsacral space in seven cases (70%), and anterior to sacrum in three cases (30%); at the aortic bifurcation, SHP strided over left iliac artery from left-hand side, then located in front of sacrum in four cases (40%), and sifted to the left at the lumbar sacral promontory in six cases (60%); from both anatomic and histological view, the autonomic nerve plexus lying in an fascia layer of retroperitoneum. At the anterior approach lumbar surgery of trans-peritoneum, we should choose the right-hand side incision; the SHP should be pushed aside carefully from right to left along intervertebral disc. The accurate surgical plane was at the deeper layer of autonomical nerve fascia; we also could lift the complete autonomical nerve layer which lies behind the aorta and lumbar sacral promontory, so that the autonomic nerve could be preserved.

Perioperative Complications in Revision Anterior Lumbar Spine Surgery

This is a retrospective review of 129 consecutive anterior lumbar revision surgeries in 108 patients. It is a single-center, multi-surgeon study. To determine occurrence rates and risk factors for perioperative complications in revision anterior lumbar fusion surgery. Although complication rates from large series of primary anterior fusion procedures have been reported, reports of complication rates for revision anterior fusion procedures are relatively rare. Concern exists chiefly about the risk to vascular and visceral structures because of scar tissue formation from the original anterior exposure. This was a retrospective review of 129 consecutive anterior revision lumbar surgeries in 108 patients operated between 1998 and 2003. There were 40 men and 68 women. The age of patients ranged from 25 to 83 (average 50.6 years). Patients were excluded if surgery was for tumor or infection. Patients were divided into 2 groups; those with revision surgery at the same level and those with revision surgery at an adjacent level. Outcome measures included all perioperative complications. Statistical analysis included Student t test and nonparametric sign-rank. The number of surgical levels treated for revision was similar between the 2 groups (1 level 69%; 2 levels 19%; 3 or more levels 12%). Revision cases at the same operative level had a higher overall complication rate (42%) compared with extensions (20%; P = 0.007). This difference was primarily because of vein lacerations (23.7% vs. 3.6%, P = 0.002). There were 2 ureteral problems, both successfully salvaged. There were no arterial injuries or deaths. Complication rates for revision lumbar surgery in this series were 3 to 5 times higher than reported for primary lumbar exposures. Complication rates were significantly higher for revision anterior lumbar fusions at the same segment, which were typically in the lower lumbar spine, compared with cases involving extensions, which were typically in the upper lumbar spine.

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

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. 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. 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. 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.

Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery

In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach. Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society-30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound. At a mean follow-up of 31 months (range 12-47 months), the mean Scoliosis Research Society-30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of >or= 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004). Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.

39. Characterization of Intraoperative Neurophysiologic Changes Due to Vascular Compression during Anterior Lumbar Surgery

BACKGROUND CONTEXT: The anterior retroperitoneal approach is often used to gain access to the anterior lumbar spine. During this approach, dissection and retraction of the aorta and iliac vessels may be required. Occult intraoperative vascular insufficiency may lead to catastrophic complications and thus early detection is critical to satisfactory patient outcomes. Intraopertive neurophysiologic monitoring (IONM) using posterior tibial nerve somatosensory evoked potentials (PTN SSEP) is an accepted technique for monitoring neural pathways during spinal procedures.

170. Perioperative Complications of Anterior Lumbar Surgery in Obese vs. Non-Obese Patients

BACKGROUND CONTEXT: Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disk replacement with reports of associated vascular and visceral complications, but the impact of obesity on these complications is unclear.

Retroperitoneal Lymphocele After Anterior Spinal Surgery

Case report; Review of Literature. To present an uncommon complication after anterior lumbar surgery as well as a treatment option and a review of the literature. A number of complications have been reported after anterior lumbar surgery. Common complications include vascular, ureteral, and neurologic injuries. The development of a retroperitoneal lymphocele has been previously been described, but details regarding evaluation, diagnosis, and treatment options are lacking in the literature. The case of a single patient with a postoperative retroperitoneal lymphocele was identified and retrospectively reviewed. Permission was obtained from the patient to review and publish this information. A review of literature on lymphoceles and anterior lumbar complications was also performed using PubMed and Ovid databases. A 76-year-old woman underwent anterior interbody fusion from L2-L3-L4-L5, followed by posterior T11-L5 fusion for degenerative scoliosis and spinal stenosis. Six weeks after surgery, she presented with severe abdominal pain, nausea, and emesis. Examination revealed a retroperitoneal lymphocele, which was confirmed after aspiration. The patient was treated with a laparoscopic marsupialization procedure without recurrence. At 12 months, the patient had no further abdominal symptoms, noted improvements in back and leg pain scores, and had stable radiographic findings. Retroperitoneal lymphocele is a rare complication after anterior lumbar interbody fusion. The different diagnosis should include infectious abscess, ureteral injury with urinoma, pancreatic injury with pseudocyst formation, and spinal fluid leak with pseudomeningocele. Diagnosis can be guided by serum and cyst fluid analysis. Although treatment options exist, surgical treatment may provide the most reliable results.

Anterior Revision of a Dislocated ProDisc Prosthesis at the L4-5 Level

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. 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. 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. 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. The patient recovered from surgery without sequelae, and her preoperative symptoms resolved. 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.

The Use of Computed Tomography Angiography to Define the Prevertebral Vascular Anatomy Prior to Anterior Lumbar Procedures

Prospective cohort. To determine the efficacy of a single-slice computed tomography (CT) angiogram to define the prevertebral anatomy in patients undergoing an anterior lumbar spine procedure. Preoperative planning with precise prevertebral anatomic details can help in mini-open anterior lumbar approaches. A total of 76 consecutive patients undergoing a minimal incision approach for anterior lumbar surgery were evaluated before surgery with CT angiography. The prevertebral anatomy was documented, and the patients were observed during treatment. There were no complications related to CT angiography. This study directly influenced surgical decision making and the treatment options in 21% of patients. The vena caval confluence limited access to the L5-S1 disc in 3% of patients and at the L4-L5 disc in 92% of the patients. Prevertebral anatomic anomalies were found in 11.8% of patients. Atherosclerotic disease was discovered in 17% of the patients. The major complication rate was 7.5%. CT angiography correlated with intraoperative vascular anatomy in all cases. Preoperative CT angiography before anterior approaches was determined to be effective in evaluating the prevertebral vascular anatomy.

An evaluation of vascular anatomy for minilaparotomic anterior L4–5 procedures

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. 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. 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.

4:45129. Maverick Total Disc Replacement: A Study of Device Position and Patient Outcomes at Two Years

gastric decompression. There were no bowel injuries, and no hernias have been reported so far. There were 2 cases of DVT at the calf and one case of ileo-femoral venous thrombosis all presenting approximately a week after surgery. Two of these were treated effectively with anticoagulation, but 1 patient expired due to bleeding from an idiosyncratic reaction to heparin. CONCLUSIONS: This study compares very favorably with published reports of complications for anterior lumbar interbody fusion (ALIF) as well as with the reported approach complication rate in the Charite FDA study, and shows that the approach for lumbar TDR can be performed safely and effectively by experienced access surgeons. The incidence of all venous lacerations at L4-5 continues to demonstrate that this is, by far, the most difficult and more dangerous level to expose. Surgeons with little or no experience in anterior lumbar surgery should attempt lumbar TDR with trepidation, especially at the L4-5 level. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. CONFLICT OF INTEREST: No conflicts.

P122. The Importance of New Strategies for Revision and Retrieval Lumbar Total Disc Replacement: Beyond the Traditional Approach - Prospective 4 Years Follow-Up Study

BACKGROUND CONTEXT: Revision indications on total disc replacement (TDR) may include implant loosening, malposition, displacement, early wear, and infection. Each indication will likely require different preoperative planning, testing, and strategies. Preoperative planning is the first and most important step in performing a revision of TDR. An organized approach reduces operative time, minimizes risks, decreases stress, and increases the success rate. Primary revision strategies for failed total disc arthroplasty can be planned as a posterior fusion, leaving the total disc replacement device in place, or by way of anterior removal with subsequent anterior fusion or revision replacement of the prosthesis. An anterior revision approach carries significant risk and should only be performed by surgeons experienced in anterior lumbar surgery.

Vascular Injury During Anterior Lumbar Surgery

Vascular Injury During Anterior Lumbar Surgery