Anterior Retroperitoneal Approach Research Articles

Intraoperative Complications of the Anterior Retroperitoneal Approach to the Lumbosacral Spine in the Supine Position: A Proposal for an Algorithm to Predict the Degree of Difficulty of the Surgical Procedure

The main concern in anterior exposure of the lumbosacral spine is the risk of vascular injury during mobilization and retraction of the blood vessels. Preoperative planning is considered essential to reducing the incidence of vascular injury, although no consensus has been reached on the preferred methodology for such planning. This is a retrospective study, including all patients operated on by a single surgeon, who received anterior lumbar-spine surgery in the supine position as a primary procedure before undergoing an anterior lumbar interbody fusion (ALIF) or an artificial disc replacement (ADR). The aim of this study was to list the intraoperative complications observed. We included 156 patients (87 women; mean age, 48 years) who met the inclusion criteria. The overall complication rate was 6.4% (10/156). The most frequent complications were an incidental peritoneal opening (seven patients, 4.4%); two left–iliac-vein injuries (1.28%) that were sutured; and one dural tear during a decompression maneuver of the canal. No neurological, arterial, or ureteral injury or retrograde ejaculation was reported. The use of a sound protocol that includes planning, assessment of approach difficulty, and step-by-step surgical technique can reduce the rate of vascular injury in anterior lumbosacral-spine surgery.

Lumbar Sympathetic Chain Tract and Mobility of Oblique Lumbar Interbody Fusion Approach: A Cadaveric Study

To assess lumbar sympathetic chain (LSC) relation to the surgical corridor for oblique lumbar approach and the ability to mobilize the LSC. Forty-three cadavers were included. Left-sided anterior retroperitoneal approach was performed in a supine position. Distance between the great vessels and psoas muscle (oblique corridor) and distance between great vessels and LSC at L2/3, L3/4, and L4/5 disc levels were measured. Mobilization of LSC at each disc level was done either close to or away from the psoas muscle and each mobilization distance was measured. The presence rates of LSC in oblique corridor were 19.5%, 43%, and 75.7% at L2/3, L3/4, and L4/5 levels, respectively. At L2/3 disc level, mean distance between psoas muscle and LSC and its mobility were 0.61±1.31 mm, and 2.72±1.24 mm, respectively. At L3/4 disc level, mean distance between psoas muscle and LSC and its mobility were 1.72±2.53 mm, and 3.11±1.02 mm, respectively. At L4/5 disc level, mean distance between psoas muscle and LSC and its mobility were 2.94±3.52 mm, and 2.53±1.03 mm, respectively. The mean width of corridor of L2/3, L3/4, and L4/5 were 10.73±5.82, 12.63±5.02, and 15.43±6.31 mm, respectively. The LSC tract usually lies in the oblique corridor in L4/5 but keeps decreasing in prevalence when approaching L3/4 and L2/3 levels. It can be mobilized a few millimeters close to or away from the psoas muscle. Care should be taken to prevent LSC injury, particularly when the LSC needs to be retracted along with the psoas muscle.

V05-12 ANTERIOR RETROPERITONEAL APPROACH TO THE SINGLE PORT PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023V05-12 ANTERIOR RETROPERITONEAL APPROACH TO THE SINGLE PORT PARTIAL NEPHRECTOMY Grace Chen and Simone Crivellaro Grace ChenGrace Chen More articles by this author and Simone CrivellaroSimone Crivellaro More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since the Food and Drug Administration’s (FDA) approval of the da Vinci Single-Port (SP) robotic platform in 2018, a wealth of new surgical techniques have been described that capitalize on the SP platform’s proficiency in small spaces. A rarely described technique even among robotic surgeons is the anterior retroperitoneal approach. To our knowledge, this is the first description of this approach utilizing the SP platform in the literature. Our objective is to describe the technique used at our institution for the anterior retroperitoneal single port partial nephrectomy. METHODS: This video abstract uses intraoperative recordings from one patient who underwent a SP partial nephrectomy at our institution. The clinical techniques are described in detail following detailed discussion with an experience robotic surgeon (SC). No pathologic or short-term outcomes were available. RESULTS: Retroperitoneal access was successfully obtained via an anterior incision for a 3.7 cm interpolar mass. The mass was successfully treated without need for conversion to multi-port or open approaches. Total operative time was 192 minutes. Total estimated blood loss (EBL) was 20 cc. The total hospital length of stay (LOS) was 8 hours. The patient was successfully discharged home with a non-narcotic pain control plan. CONCLUSIONS: The anterior retroperitoneal approach to SP robotic partial nephrectomy is safe and feasible. Theoretical advantages of this approach include increased efficiency and decreased positional injuries due to the ability to perform surgery in the supine position, less bowel manipulation, and potentially decreased opioid requirements. Further outcomes data is anticipated. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e428 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grace Chen More articles by this author Simone Crivellaro More articles by this author Expand All Advertisement PDF downloadLoading ...

Anterior Transpsoas Approach for Removal of Cement Leakage after Sacroplasty.

Sacroplasty is a minimally invasive treatment option for severe pain due to sacral insufficiency fracture. Cement leakage is a known risk of sacroplasty. Despite the elevated risk to the L5 nerve root and lumbosacral trunk from cement leakage anterior to the sacral ala, there are no reports regarding surgical management of this complication. We describe an anterior retroperitoneal transpsoas approach to the sacral ala to remove cement leakage causing acute L5 radiculopathy in a 57-year-old gentleman who had undergone sacroplasty for sacral insufficiency fracture (Denis zone 1). The approach provides rapid and excellent visualization of the sacral ala without manipulation of the iliac vessels. We recommend that surgery be considered in a timely fashion, to utilize neuromonitoring, and that surgeons be aware of the considerable variability of the neurologic structures that will be encountered, which is described in this technical note.

L4 Corpectomy: Surgical Approaches and Mitigating the Risk of Femoral Nerve Injuries

Because of the challenging anatomic location, corpectomies are performed less often at the fourth lumbar vertebral body than at other levels. Our objective was to review the literature of L4 corpectomy and anterior column reconstruction. A literature search in the Medline/PubMed database was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify all relevant cases and cases series describing corpectomies of the L4 vertebral body using "lumbar" AND "corpectomy" as search terms. We present an illustrative case to describe the technique. We identified 18 articles with 30 patients who met the search criteria. Including our case illustration, the most common approach used was the lateral retroperitoneal approach (n= 17, 54.8%), of which 8 (26.7%) were performed via a transpsoas approach. Seven (23%) patients underwent corpectomy through a posterior approach, 4 (12.9%) through an anterior retroperitoneal approach, and 3 (10%) through combined anterior and lateral retroperitoneal. The overall complications rate was 19.3% including 1 case each of femoral nerve injury and iatrogenic lumbar nerve root injury. Corpectomies of the L4 vertebral body are challenging. None of the various approaches described clearly demonstrates any superiority in mitigating the risk of neural complications. Decision making about which surgical approach to use should be based on patient-specific characteristics.

Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note.

Increasingly there is an impetus on the part of surgeons to find more minimally invasive approaches to treat spinal pathologies. Retroperitoneal prepsoas and transpsoas approaches to the lumbar spine are one such example gaining increased attention. Endoscope-assisted approaches may help further reduce soft tissue dissection. To describe an endoscope-assisted lateral retroperitoneal prepsoas approach for lumbar diskectomy. Two fresh-frozen thoracolumbar cadaveric specimens were obtained and placed in the right lateral decubitus position. Using a left-sided, retroperitoneal prepsoas approach to the lumbar spine and under endoscopic visualization, diskectomies were performed at the L2/3, L3/4, L4/5, and L5/S1 intervertebral spaces. Qualitative assessment of the extent of central and contralateral foraminal decompression was performed. The endoscope was found to provide effective visualization at all disk spaces and combined with the anterior retroperitoneal prepsoas approach allowed for effective decompression of all explored disk spaces. Both operators noted difficulty obtaining visualization of the ipsilateral foramen, but adequate central and contralateral foraminal decompression was achievable for central, paracentral, and contralateral far lateral disk protrusions. Endoscope assistance may improve visualization of the lumbar intervertebral disk spaces during retroperitoneal prepsoas approaches and thereby help to expand the surgical indication for anterior and oblique lumbar interbody fusion.

Chylothorax, a rare complication after anterior lumbar interbody fusion. Case report.

Chylous leakage into the retroperitoneum is a rare complication after spinal surgery using an anterior retroperitoneal approach. Chylothorax is the presence of lymphatic fluid in the pleural cavity and it is even less frequent during these surgeries. The aim of this work is to report the first case of isolated left chylothorax after a retroperitoneal Left Oblique Lumbar Interbody Fusion in supine position in an adult female patient. A female 30-years-old patient underwent L4-L5 anterior interbody fusion. Four days after the intervention she was diagnosed with isolated left chylothorax that was drained and treated conservatively with good outcomes. Chylothorax is an extremely rare complication after anterior lumbar spine procedures, and it is usually secondary to a chyloretroperitoneum. We present a unique case of isolated chylothorax after anterior retroperitoneal lumbar approach successfully treated in a conservative manner. Key Words chylothorax; spine; lumbosacral region; arthrodesis.

Minimally invasive stand-alone fusion of the lumbosacral junction

Stable interbody fusion of the lumbosacral segment via an anterior retroperitoneal approach using an interbody spacer as an anterior stand-alone device which is fixed with four locking screws. Degenerative disc disease without instability or deformity; adjacent segment degeneration; pseudarthrosis. Translational instabilities as in spondylolisthesis at the index segment; deformities; steep sacral slope. Challenging vascular situation with aortic bifurcation and/or venous confluence in front of L5/S1; osteoporosis. Relative: previous abdominal/gynecological surgery; infection/tumor/trauma. Access to the lumbosacral junction via amini-open laparotomy using aretroperitoneal approach, insertion of aretractor system, preparation of the lumbosacral segment and complete discectomy and endplate preparation, distraction of the disc space, assessment of the adequate implant size, packing of the device and the disc space with bone graft substitute, insertion of the device in the intervertebral space, fixation of the implant by inserting two screws each into the cranial and caudal vertebral body, X‑ray control, withdrawal from the surgical site under constant assessment for possible lesions, wound closure. Immediate full load-bearing mobilization within 4-6 h postoperatively, external brace optional, resumption of sporting activities 3-6months postoperatively. From 2005-2012, of the original 77patients who underwent surgery, 71patients (26men, 45women; 92.2%) were followed up for anaverage of 35.1months (range 12-85months). The overall complication rate was 12.7%; the reoperation rate was 2.8%. At final follow-up, 77.5% of the patients were satisfied and 22.5% were not satisfied. The ODI and the VAS scores revealed significant improvements over the entire follow-up period. X‑ray analysis demonstrated asignificant improvement of segmental lordosis. Solid bony fusion (determined by CT) was observed in 97.3%.

Management of Chyloretroperitoneum After Lumbar Surgery by Anterior Approach

Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%-3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through2017. The literature review was conducted using the terms "chyloretroperitoneum," "spinal surgery," and "lymphocele." Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented. In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n= 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure. Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography-guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.

Surgical methods of treatment of back pain syndrome recurrence in the degenerative pathology of the lumbar spine

The number of surgical interventions on the lumbar spine is constantly growing due to the emergence of new surgical techniques aimed at treatment of degenerative spine pathology and a large number of patients, suffering from the back pain. Quite often, surgical intervention turns to be not effective enough and the pain syndrome persists, leading to the necessity for the repeated revision surgeries with the use of stabilizing systems. The review represents research data on the causes of recurrent-remitting course of degenerative process, problems of epidural adhesion as one of the back pain syndrome predictors, the survey of various stabilization systems and operative approaches for their implantation. The disadvantages and advantages of ventral approach with the use of interbody fusion are summarized in comparison with dorsal approach used for the installation of the transpedicular system and interbody fusion with a bone graft. The positive features of interbody fusion from anterior retroperitoneal approach include the ability to quickly and completely remove the entire disc, decompress the dural sac without entering the vertebral canal, optimally select an implant corresponding to the size of the vertebral end plates, creation of the optimal lordosis angle, and provision of the shortest approach to the operated disk and to the place of neural structures compression. The advantages of the dorsal approach with transpedicular system implantation and interbody fusion with a bone graft are better visualization of neural structures in comparison with discectomy from the ventral approach, the possibility of wide decompression and expansion of the extent of operation, the possibility of ablation of the facet joints by diathermocoagulation after the surgical wound was made, the reliability of posterior fixation, and familial approaches for a neurosurgeon with a lesser duration of training.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 15. Decreased operative time and estimated blood loss in lateral trans psoas versus anterior approach to lumbar interbody fusion for degenerative spondylolisthesis

BACKGROUND CONTEXT The lateral trans psoas approach was introduced as a less-invasive alternative with potentially accelerated postoperative recovery relative to the traditional anterior approach to lumbar interbody fusion. Lumbar fusion through the lateral trans psoas approach is associated with low estimated blood loss, improvement in postoperative patient reported outcomes, and low complication rates, but is also associated with exposure-related sensory and motor changes in the ipsilateral lower extremity. Both anterior and lateral trans psoas approaches for single level fusions at any lumbar segment yield similar complication rates, radiographic and early clinical outcomes. There is, however, a paucity of literature specifically comparing anterior lumbar interbody fusion with lateral trans psoas for degenerative spondylolisthesis. PURPOSE The goal of the study was to compare outcomes of lateral trans psoas versus anterior approaches to lumbar interbody fusion for single level degenerative spondylolisthesis. The hypothesis is that lateral trans psoas lumbar interbody fusion for degenerative spondylolisthesis results in less estimated blood loss and operative time as well as similar postoperative patient-reported outcomes, without increasing complications rates, compared to anterior lumbar interbody fusion. STUDY DESIGN/SETTING The study was a retrospective cohort of consecutive patients undergoing single-level interbody fusion for L4-5 degenerative spondylolisthesis via anterior retroperitoneal or lateral trans psoas approach between 2008 and 2012 at a single academic center. PATIENT SAMPLE Patients undergoing lumbar interbody fusion at the L4-5 level for degenerative spondylolisthesis at a single academic center. OUTCOME MEASURES Differences in patient demographics, peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index) were assessed. METHODS Differences between groups were assessed with chi-squared or Fisher's exact tests, with a two-sided level of significance of α=0.05. Mean and 95% confidence intervals (CI) were reported for normally distributed variables, versus median and interquartile range (IQR) for non-normally distributed variables, RESULTS Both estimated blood loss during surgery (median 100 ml, IQR 50-100 ml) and operative time (241 minutes, CI 209-273 minutes) were significantly less for lateral trans psoas approach than for anterior approach (median 250 ml, IQR 150-400 p CONCLUSIONS The lateral trans psoas approach is associated with diminished blood loss and operative time compared to the anterior approach, without an increase in complication rates or difference in patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Anterior lumbar discectomy and fusion for acute cauda equina syndrome caused by recurrent disc prolapse: report of 3 cases

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage. The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain. ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

Early experience with lateral lumbar total disc replacement: Utility, complications and revision strategies

Lumbar total disc replacement (TDR) is an alternative to interbody fusion for the treatment of symptomatic degenerative disc disease. Traditionally, lumbar TDR is performed via an anterior retroperitoneal approach with regional risks of vascular and visceral injury. The direct lateral retroperitoneal, transpsoas approach avoids mobilisation of the great vessels and preserves the anterior longitudinal ligament, thereby maintaining physiological limits on motion. This study aimed to (i) report one site’s early experience with lateral lumbar TDR and (ii) provide case examples illustrating the utility, complications and revision strategies of the XL-TDR device. Data were collected prospectively on the first 12 consecutive patients treated with XL-TDR. Patient outcomes included pain (VAS), disability (ODI), and quality of life (SF-36 PCS and MCS). Mean follow-up was 27.5months (range 18–48months). Patients had significant improvements in back (74%) and leg (50%) pain, ODI (69%), PCS (50%) and MCS (39%) (P<0.05). Two patients had early prosthesis dislocation due to prosthesis undersizing. The same skin incision was used to retrieve the XL-TDR and perform salvage lateral lumber interbody fusion, with solid fusion by 12months. Lumbar TDR using the XL-TDR via a lateral transpsoas muscle-splitting approach is a minimally invasive alternative to anterior retroperitoneal exposures for motion preservation. Correct sizing of the XL-TDR and complete contralateral annulectomy with annulus box cutters mitigates the risk of lateral dislocation. Revision surgery for lateral dislocation of the XL-TDR is more straightforward compared to anterior TDR dislocation.

The role of anterior interbody fusion (ALIF and XLIF with anterior column release) in the surgical management of adult spinal deformity

Anterior interbody fusions are commonly used in the treatment of adult spinal deformity. The addition of anterior fusions to posterior constructs offers increased construct stability, improved fusion rates, and better lordosis restoration. The anterior column is most commonly accessed by the anterior retroperitoneal approach, in which the anterior longitudinal ligament is resected, or by the lateral transpsoas approach, which offers the ability to either leave the anterior longitudinal ligament intact or resect it as part of anterior column realignment. Complications are mostly approach-related and include vascular, visceral, and neurological injury.

Is lumbar disc degeneration due to low-grade infection – A prospective study by anterior retroperitoneal approach

Study design Prospective study of microbiological culture with biopsy of intervertebral disc material with anterior retroperitoneal approach surgery of patient presenting lumbar disc degeneration. Objective To determine if a low-grade infection really plays a role in lumbar disc degeneration. Summary of background data Many recent studies found a significant prevalence of bacteria in lumbar disc material taken during posterior arthrodesis or microdiscectomy but the hypothesis of biopsy contamination cannot be excluded. Methods Three hundred and thirteen patients (186 females, 127 males, 46,5y) with low back pain due to lumbar disc degeneration, unresponsive to medical treatment, were included in this series. Pfirrmann stages in MRI were IV or V; 281 patients were Modic I and 21 were Modic II. They were treated by anterior retroperitoneal interbody arthrodesis (ALIF) or lumbar disc replacement on L4–L5 or and L5–S1; an intraoperative biopsy and microbiological culture were performed for each disc during the surgery. Results Three hundred and sevent cultures were sterile (98%). The bacteria founded in the 6 positive cultures were Propionibacterium acnes (2), Staphylococcus epidermidis (2), Citrobacter freundii (1), and Saccharopolyposa hirsuta (1). None of the biopsy founded multinucleated cells or inflammatory response. None of the patients developed infectious symptoms until 1-year follow-up. Discussion and conclusion Anterior retroperitoneal approach was for us the safer way to avoid disc's biopsy contamination compared to classical posterior approach. At first sight, there is no relationship between a bacteria and the process of disc degeneration. Therefore, it is seems unfounded to treat low back pain with antibiotics, despite the good results. It should be recognized that the physiopathlogy of disc degeneration has not yet been clarified.

Anatomic feasibility of a new endopelvic approach for iliac crest bone harvesting.

For the past few years, anterior exposure for surgery of the lumbar spine has gained popularity for the treatment of disk disease or spondylosis. Cancellous bone remains the gold standard for fusion. Iliac crest bone harvesting is safe but there are donor site complications. Bone substitutes exist, like recombinant human bone morphogenic protein-2 rhBMP-2. This alternative offers a high rate of fusion but with local and general complications. The aim of our study is to show the feasibility of an endopelvic approach for iliac bone crest harvesting to avoid donor site complication. Twenty anterior retroperitoneal lumbar spine approaches have been realized in the anatomy department of the University of Bordeaux. The volumes of cancellous bone have been measured and procedure complications have been reported. The mean volume of cancellous bone was 5.9cc, the maximum volume was 8.2cc and the minimum volume was 4.5cc. No complications have been reported during the approach or the bone harvesting. Anterior retroperitoneal approach for iliac bone crest harvesting is a safe way to obtain sufficient volume of cancellous bone for a single lumbar spinal fusion. This exposure avoids the risks of an iliac crest donor site complications or rhBMP-2 complications.

Management of an unusual sciatica

Extraforaminal entrapment of the L5 nerve root is uncommon, and its management can sometimes be very challenging. We present the case of a 57-year-old female, complaining of a sciatica in her left leg, for 3years, with no response to any kind of conservative treatment. MRI and CT scan revealed the presence of a large L5S1 strictly lateral osteophyte compressing the left L5 root in its extraforaminal path. The patient underwent a left anterior retroperitoneal approach with assistance from a vascular surgeon given the very close relation between the osteophyte and the left common iliac vein, lying just on top of it, osteophyte was removed in one piece with the use of an osteotome after retraction of the vessels. The patient progressively recovered from her left sciatic pain with a satisfactory clinical result at 1year. Literature is sparse on the treatment of extraforaminal entrapment of the L5 nerve root; the current case shows a successful treatment strategy with the use of an anterior approach for direct vision of the lesion and good control of the vessels.

Prospective study using anterior approach did not show association between Modic 1 changes and low grade infection in lumbar spine.

The modern literature is producing a rapidly growing number of articles which highlight the relationship between infection and lumbar disc degeneration. However, the means by which samples are collected is questionable. Posterior approach surgery is not free from skin contamination. The possibility of intraoperative contamination of disc biopsies cannot be excluded. The objective of this study was to determine if an association existed between lumbar disc degeneration and chronic infection of the intervertebral disc. 313 patients (186/127, F/M) with chronic low back pain secondary to degenerative disc disease which was resistant to medical treatment were included in a single-centre prospective study. All underwent a lumbar anterior video-assisted minimally invasive fusion or disc prosthesis in L4-L5 and/or L5-S1 via an anterior retroperitoneal approach. The patients MRI scans demonstrated in Pfirrmann's classification grade IV or V disc degeneration; 385 disc drives were taken. In terms of Modic changes, 303 Modic 1, 58 Modic II and 24 absence of Modic change, respectively. All underwent intraoperative biopsy, performed according to a strict aseptic protocol. The biopsies were then cultured for 4 weeks with specialised enrichment cultures and subjected to histopathological analysis. The mean age was 47 ± 8.6 years sterile cultures were obtained in 379 samples (98.4%) and 6 were positive (1.6%). The cultured bacteria were: Propionibacterium acnes (n:2), Staphylococcus epidermidis (n:2), Citrobacter freundii (n:1), and Saccharopolyspora hirsuta (n:1). Histopathological analysis did not demonstrate any evidence of a neutrophilia. There were no delayed or secondary infections. Unlike the posterior approach where contamination is common, the anterior video-assisted approach allows a biopsy without skin contact. This approach to the spine is the most effective way to eliminate the risk of contamination. Our results confirm the absence of any relationship between infection and disc degeneration. We suggest that the 6 positive samples in our study may be related to contamination. The absence of infection at 1-year followup is an additional argument in favour of our results. In conclusion, our study shows no association between infection and disc degeneration. The pathophysiology of disc degeneration is complex, but the current literature opens new perspectives.

Video-Assisted Anterior Retroperitoneal Approach to the Lumbar Spine. A Minimal Invasive Technique Improved by the Use of Endoscopic Camera to Treat Lumbar Spine Diseases

The anterior retroperitoneal approach is a technique to treat disc degenerative disease (DDD), spinal deformities, traumas, tumors and infections. It can be used to perform Anterior Lumbar Interbody Fusions (ALIF) or Total Disc Replacements (TDR). Though being a fast procedure that is becoming more often used by spinal surgeons, the anterior approach requires an adequate knowledge of the anatomy of the abdomen to lessen the risks of intraoperative complications. The authors’ preferred technique is the left retroperitoneal video-assisted approach, using an endoscope to visualize and magnify the deep anatomical structures, discectomy procedure and hardware implant. In a review of our casuistry from 2010 to 2012, 163 patients underwent an anterior lumbar approach, and 139 of these had a single L4-5 or L5-S1 level treatment. A 3.6% rate of global complications (1.44% of major vascular injuries) has been observed, with a mean operation time of 116.4 minutes and a mean blood loss of 156.1 ml. These values show how the anterior retroperitoneal video-assisted approach for the treatment of lumbar diseases is a fast procedure that implies low blood loss, with a low rate of intraoperative complications.

Anterior Column Realignment (ACR) in Adult Sagittal Deformity Correction: Technique and Review of the Literature.

The anterior column realignment (ACR) procedure was retrospectively reviewed. To review surgical technique, complication avoidance, case examples, and published results on ACR. For surgical correction of sagittal imbalance, three column osteotomies (3CO) have traditionally been employed for large degrees of correction at a single segment. However, 3CO procedures are technically challenging and carry high morbidity rates. ACR was developed as a less invasive procedure for restoring segmental lordosis. The ACR surgical technique is reviewed. ACR involves either a lateral, trans-psoas or anterior retroperitoneal approach to sectioning the anterior longitudinal ligament/annulus and placing a hyperlordotic cage. ACR usually also involves a second stage posterior column osteotomy. Three case examples are presented. A review of literature on ACR papers was completed. Twelve papers met inclusion criteria. Ten to 27° of segmental lordosis were reported with use of hyperlordotic cages. 19° increase in mean intradiscal angle was reported when ACR was combined with posterior column osteotomy, 13° more than lateral lumbar interbody fusion alone without a hyperlordotic implant. Reported complication rates ranged from 18 to 47%. The most common minor complications were transient hip flexion weakness (9.3%) and transient paresthesia or dysesthesia (12%). There were few reports of major complications, such as bowel perforation (n = 1) or vascular injury (n = 1). Motor deficit was reported in 11 of 75 cases, lower than reported rates for 3CO. ACR is an emerging, less invasive technique for correction of sagittal deformity ACR has similar restorative capacity as other techniques with same or lower complication rates. 4.