Traditional Posterior Approach Research Articles

Access to the Lumbosacral Spine: A Current View.

The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Posterior Transdural Approach for Thoracic Corpectomies in the Setting of Complex Spine Deformity Reconstruction.

There are many surgical approaches for execution of a thoracic corpectomy. In cases of challenging deformity, traditional posterior approaches might not be sufficient to complete the resection of the vertebral body. In this technical note, we describe indications and technique for a transdural multilevel high thoracic corpectomy. A 25-year-old man with a history of neurofibromatosis type 1 presented with instrumentation failure after a previous T1-T12 posterior spinal fusion, extensive laminectomy, and tumor resection. The patient presented with progressive back pain, had broad dural ectasia, and a progressive kyphotic rotational and anteriorly translated spinal deformity. To resect the medial-most aspect of the vertebral body, a bilateral extracavitary approach was attempted, but was found insufficient. A transdural approach was subsequently performed. A left paramedian durotomy was made, followed by generous arachnoid dissection, bilateral dentate ligament division, and T4 rootlet sacrifice to mobilize the spinal cord. A ventral durotomy was then made and the ventral dura was reflected over the spinal cord to protect it while drilling. The corpectomy was then completed. The ventral and dorsal durotomies were closed primarily and reinforced with fibrin glue and fibrin sealant patch. The corpectomy defect was filled with nonstructural autograft. The focal kyphosis was corrected with a combination of rod contouring, compression, and in situ bending. During the surgery, the patient had stable neuromonitoring data, and postoperatively had no neurological deficits. On follow-up until 1 year, the patient presented with no signs of cerebrospinal spinal leaks, no motor or sensory deficits, minimal incisional pain, and significantly improved posture. Complex high thoracic (T3-5) ventral pathology inaccessible via a bilateral extracavitary approach may be accessed via a transdural approach as opposed to an anterior/lateral transthoracic approach that requires mobilization of cardiovascular structures or scapula.

Comparative analysis of short-term therapeutic efficacy between percutaneous endoscopic transforaminal technique and traditional posterior approach decompression, interbody fusion, and internal fixation for the treatment of geriatric degenerative lumbar spinal stenosis.

Comparative analysis of short-term therapeutic efficacy between percutaneous endoscopic transforaminal technique and traditional posterior approach decompression, interbody fusion, and internal fixation for the treatment of geriatric degenerative lumbar spinal stenosis.

A Comparison of Hidden Blood Loss Between Multilevel Posterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in Adult Spinal Deformity Patients.

Retrospective cohort study. This study aimed to compare transfusion and blood loss volumes, particularly hidden blood loss volume, in adult spinal deformity patients undergoing lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF). Corrective surgery for adults with spinal deformity patients can be performed via the traditional posterior approach (PLIF) or minimally invasive lateral approach (LLIF). LLIF is associated with longer or comparable operation times and lower intraoperative blood loss. However, hidden blood loss has not been compared between the two procedures. We compared hidden blood loss and other blood loss volumes, transfusion volume, operation time, and radiographic surgical outcomes between LLIF patients (n = 71) and PLIF patients (n = 33) who underwent surgery in our institution from September 2011 to June 2018. All patients provided informed consent in accordance with the Declaration of Helsinki. Institutional ethics committee conducted this study approval was obtained. Transfusion volume and intraoperative and total blood loss volumes were significantly higher in the PLIF group. Operation time and HBL did not significantly differ. The hidden blood loss-to-intraoperative blood loss ratio was significantly higher in the LLIF group (113% vs 60%; P = .004). Radiographic measures of outcome were significantly better after surgery than before in both groups. Although intraoperative blood loss was less with LLIF than PLIF, HBL was similar between the approaches. Patients undergoing LLIF should be followed closely for postoperative anemia even if intraoperative blood loss is low.

Modified anterior approach versus traditional posterior approach for ultrasound-guided superior laryngeal nerve block in awake endotracheal intubation: a randomized non-inferiority clinical trial

Study objective This study was undertaken to compare the effect of the modified ultrasound-guided anterior superior laryngeal nerve block (SLNB) with the traditional ultrasound-guided posterior SLNB in providing intubation conditions during awake tracheal intubation (ATI) in patients without difficult airway. Design Randomized, assessor-blind. Registration number: ChiCTR2200058086. Setting West China Hospital of Sichuan University, Chengdu, China. Patients 104 patients aged 18–65 years, of American Society of Anesthesiologists status I-III, posted for elective general surgery with general endotracheal anesthesia. Interventions The patients were randomized into two groups (modified group, n = 52; traditional group, n = 52). Modified anterior SLNB or traditional posterior SLNB was performed under ultrasound guidance. Measurements The primary outcome was the proportion of acceptable intubation condition (AIC), which was analyzed in both per-protocol (PP) and intention-to-treat (ITT) populations. The prespecified non-inferiority margin was −4.8%. Secondary outcomes included intubation success rate on the first attempt, hemodynamic parameters during ATI, time taken for airway anesthesia and intubation, recall of intubation, patient perception of comfort, and incidence and severity of postoperative complications. Main results In the PP population, the proportion of AIC in the modified group was 49/49 (100%) and that in the traditional group was 49/49 (100%), absolute difference 0, lower limit of 1-sided 95% CI, −0.3%. In the ITT population, the primary outcomes in the modified and traditional group were 52/52 (100%) and 51/52 (98.1%), respectively, with an absolute difference of 1.9% and a lower limit of 1-sided 95% CI of −1.2%. The non-inferiority of modified ultrasound-guided anterior SLNB was confirmed in both populations. Conclusions Among adults without difficult airways during videolaryngoscope-assisted ATI, the modified ultrasound-guided anterior SLNB, compared to the traditional posterior approach, showed a statistically non-inferior effect in terms of providing AIC.

Lumbar lateral interbody fusion: step-by-step surgical technique and clinical experience.

Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical approach used to treat a variety of degenerative and deformity conditions of the lumbar spine such as advanced degenerative disease, degenerative scoliosis, foraminal and central stenosis. It has emerged as an alternative to the traditional posterior and anterior lumbar approaches with some potential benefits such as lower blood loss and shorter hospital stay. In this article, we provide our single institutional surgical experience including main indications and contraindications, a step-by-step surgical technique description, a detailed preoperative imaging assessment with a focus on magnetic resonance imaging (MRI) psoas anatomy, operative room (OR) setup and patient positioning. A descriptive surgical technical note of the following steps is provided: positioning and fluoroscopic confirmation, incision and intraoperative level confirmation, discectomy and endplate preparation, implant size selection and insertion and final fluoroscopic control, hemostasis check and wound closure along with an instructional surgical video with tips and pearls, postoperative patient care recommendations, common approach-related complications, along with our historical clinical institutional group experience. Finally, we summarize our research experience in this surgical approach with a focus on LLIF as a standalone procedure. Based on our experience, LLIF can be considered an effective surgical technique to treat degenerative lumbar spine conditions. Proper patient selection is mandatory to achieve good outcomes. Our institutional experience shows higher fusion rates with good clinical outcomes and a relatively low rate of complications.

Clinical Efficacy and Imaging Observation of Three Surgical Approaches in Treatment of Thoracolumbar Fractures.

To observe the efficacy and imaging of surgical treatment of thoracolumbar fractures via the paravertebral muscle space approach. A retrospective analysis was conducted on patients with thoracolumbar fractures receiving surgery in Baoding First Central Hospital from January 2019 to December 2020. According to different surgical approaches, they were divided into paravertebral approach group, posterior median approach group and minimally invasive percutaneous approach group. They received surgery via the paravertebral muscle space approach, posterior median approach and minimally invasive percutaneous approach, respectively. Statistically significant differences were found in surgical duration, intraoperative bleeding volume, intraoperative fluoroscopy frequency, postoperative drainage volume and hospital stay among the three groups. One year after surgery, the VAS, ADL and JOA scores of the paravertebral approach group and the minimally invasive percutaneous approach group had statistically significant differences from the posterior median approach group (P < 0.05). For the surgical treatment of thoracolumbar fractures, the clinical efficacy of the paravertebral muscle space approach is superior to that of the traditional posterior median approach, and the clinical efficacy of the minimally invasive percutaneous approach is similar to that of the posterior median approach. All the three approaches can effectively improve the postoperative function and pain symptoms of patients without increasing the incidence of complications. Compared with the posterior median approach, the surgery via the paravertebral muscle space and minimally invasive percutaneous approaches presents shorter surgical duration, less bleeding and shorter hospital stay, which is more conducive to postoperative recovery of patients.

Influence of the facet joint angle on facet joint degeneration following pedicle screw fixation without fusion in thoracolumbar fractures.

Posterior approach pedicle screw fixation without fusion is widely used in the treatment of neurologically intact type A3 thoracolumbar fractures. To analyze the influence of the facet joint (FJ) angle on FJ degeneration following posterior approach pedicle screw fixation without fusion in neurologically intact type A3 thoracolumbar fractures. Fifty-eight patients who underwent pedicle screw fixation via the traditional posterior approach (n= 28) or the Wiltse approach (n= 30) were enrolled. A CT scan was performed before fixation and before fixation removal (Within 1.5 to 2 years after fixation) to evaluate the FJs parameters, including FJ inclination (FJI), FJ tropism (FJT), FJ violation, and FJ degeneration grade (FJDG), of three fixed segments and the adjacent segment below the fixed segments. There was no significant difference in FJ violation rate, FJDG deterioration, or FJ angle between the two groups (P> 0.05). FJDG deterioration showed a weak positive correlation with FJI and FJT before fixation, and the angular change in FJI (P< 0.05); and FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration (P< 0.01). The Wiltse approach did not increase the rate of FJDG deterioration and FJs angle changes. However, the FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration.

Occipital interhemispheric transtentorial approach in pediatric patients for lesions of the superomedial cerebellum: operative findings and results.

The occipital interhemispheric transtentorial (OITT) approach is frequently used for accessing the pineal region. There are scarce reports of using the OITT to access superior cerebellar lesions. This approach affords the patient several advantages over traditional posterior fossa approaches. This study is to describe and evaluate clinical outcomes in a single surgeon case series of the OITT approach for pediatric patients with lesions of the superior cerebellum. All pediatric patients who underwent an OITT craniotomy for a superior cerebellar lesion by a single surgeon over a 5-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Thirteen pediatric patients were identified. Cases included twelve tumors and one arteriovenous malformation. Gross total resection was achieved in 92% of cases. No patients developed posterior fossa syndrome. Two patients had transient homonymous hemianopsia that resolved by 1month post-operatively. There were no permanent neurological deficits. For superomedial cerebellar lesions presenting to the tentorial surface of the superior cerebellum in patients with normal to steep tentorial angles, the OITT approach is effective and safe. This approach has a low risk of posterior fossa syndrome and permanent visual deficits when applied appropriately. Patient selection is critical for maximizing the advantages of the OITT for superior cerebellar lesions.

Paramedian Wiltse Approach for Giant Paraspinal Lumbar Schwannoma: Technical Note and Alternative Approaches.

Paraspinal lumbar schwannomas are primarily located outside of the spinal canal with minimal extension into the neural foramen. Approaching these tumors through a traditional posterior approach can be challenging given their lateral location to the spine and is likely to require extensive bony removal and potential destabilization of the spine. Alternatives approaches have been identified that may circumvent the need for extensive bony removal. To examine the use of the paramedian Wiltse approach for giant extraspinal tumors and compare the approach with other nonposterior approaches. We present 2 cases in which the paramedian Wiltse approach is used to effectively approach large paraspinal schwannomas and achieve complete tumor resection without destabilization of the spine. The paramedian Wiltse approach along with expandable retractors systems were able to achieve complete resection of the giant paraspinal schwannomas. Neural preservation was able to be achieved in one case which was facilitated by the exposure achieved through the posterior paramedian corridor that allowed for visualization of the proximal and distal ends of the tumor. The paramedian Wiltse approach is an ideal approach to target large extraspinal schwannomas for complete resection and potential neural preservation without the need for destabilization of the spine.

Techniques for psoas navigation in lateral lumbar interbody fusion

Lateral Lumbar Interbody Fusion (LLIF) is a minimally-invasive, retroperitoneal surgical technique utilized as an alternative to direct anterior and traditional posterior approaches. LLIF can be performed as a trans-psoas or psoas-sparing approach. The majority of LLIF systems utilize neuromonitoring to minimize nerve root injury. The purpose of this manuscript is to review the methods of neuromonitoring and navigation employed in LLIF, and discuss potential advances on the horizon.

Assessment of vertebral bone mineral density and stand-alone oblique lumbar interbody fusion for adjacent segment disease and primary lumbar degenerative diseases.

To evaluate the vertebral bone mineral density and the value of stand-alone oblique lumbar interbody fusion (SA OLIF) for the management of single-level adjacent segment disease (ASD) and primary lumbar degenerative diseases. Seventy-eight patients undergoing single-level SA OLIF was divided into index surgery group (n = 36) or revision surgery group (n = 42) at single center. The vertebral body Hounsfield units (HU) value was measured to assess bone mineral density of operated level by the preoperative CT. The following data were retrospectively collected and compared between the two groups: demographic, surgical data, clinical results, and complications. No differences were found between the two groups in surgical data. The fusion segment HU values in the revision group were significantly higher than that in the index group (147.4 ± 35.3 vs 129.2 ± 38.4 p = .033). There were significant differences while comparing fusion segment HU values to L1-L4 horizontal plane (147.4 ± 35.3 vs 126.1 ± 28.4, p = .000) and L1 (147.4 ± 35.3 vs 126.8 ± 26.2, p = .000) in revision group, meanwhile, no statistically significant difference was observed in index group (p > .05). The cage subsidence was observed in the revision group (n = 2) and index group (n = 9) (p = .045). The patients with cage subsidence had significantly lower vertebral HU values. SA OLIF is valid alternative to the traditional posterior approach in the management of ASD with good clinical outcomes at short-term follow-up. Increased HU values of fusion segment may play a role in the management of ASD by SA OLIF.

Analysis of the Advantages of Wiltse Approach Ligamentotaxis Method for Thoracolumbar Fractures

The Wiltse approach ligamentotaxis (WALT) is a combination of paravertebral muscle natural gap access and posterior longitudinal ligament tension, which can achieve good fracture repositioning and indirect spinal canal decompression, thus avoiding the disadvantages of traditional posterior direct decompression approach. This paper provides a detailed explanation and analysis of WALT through clinical cases.

Herniation of the Mastoid Segment of the Facial Nerve During Cochlear Implantation Surgery.

We aim to report a rare case of a herniated mastoid segment of the facial nerve that was accidently discovered during cochlear implantation surgery and how altering the surgery plan could achieve the implantation while preserving the nerve. A four-year-old girl presented with profound bilateral sensorineural hearing loss that did not completely resolve after 2years of using hearing aids was scheduled for cochlear implantation surgery in the right ear. During surgery, a herniated mastoid segment of the facial nerve took an anterior course and obstructed the access to the round window. When a traditional posterior tympanotomy approach in cochlear implantation surgery is limited in cases of a herniated facial nerve, a tunnel created near the inferior part of the posterior wall of the auditory canal provided safe insertion of the electrode. It also permitted placement of a piece of fascia between the electrode and the facial nerve, therefore, protecting the facial nerve from electrical stimuli.

Effect of percutaneous minimally invasive pedicle screw internal fixation in the treatment of thoracolumbar vertebral fractures and its impact on quality of life.

ABSTRACTObjectives:To investigate and analyze the effect of percutaneous minimally invasive pedicle screw internal fixation in the treatment of thoracolumbar vertebral fractures and its impact on quality of life.Methods:Fifty patients with thoracolumbar vertebral fracture admitted to our hospital from January 2015 to December 2018 were selected and divided into two groups according to different treatment regimens. The observation group was treated with minimally invasive percutaneous pedicle screw internal fixation, while the control group was treated with traditional posterior approach open pedicle screw internal fixation. The surgery time, incision length, intraoperative blood loss, postoperative drainage, hospitalization time, ambulation time, fracture healing time and postoperative VAS scores were compared between the two groups. In addition, the cobb angle, the sagittal plane index, and the anterior vertebral height were compared between the two groups before and after surgery, as were the Oswestry Disability Index (ODI) at 1d, 3 months, and 6 months postoperatively.Results:The surgery time, incision length, postoperative pain level, postoperative drainage and intraoperative blood loss of the observation group were less than those of the control group (P<0.05). The postoperative Cobb angle of the two groups decreased, the sagittal plane index as well as the anterior vertebral height increased (P<0.05). The Oswestry index of the observation group was better than that of the control group at one day and three months postoperatively, with a statistical significance between the two groups (P<0.05). The complication rate of the observation group was significantly lower than that of the control group (P<0.05).Conclusion:Percutaneous minimally invasive pedicle screw internal fixation is safer than the traditional open pedicle screw internal fixation, and it is more worthy of clinical promotion.

Minimally Invasive Posterior Cervical Discectomy: 2-Dimensional Operative Video.

Minimally invasive posterior cervical microdiscectomy is an appropriate surgical approach for patients with foraminal stenosis from herniated disc with radicular symptoms that is not responsive to conservative management. While anterior cervical discectomy and fusion (ACDF) or arthroplasty is increasingly utilized to treat herniated disc, a posterior approach eliminates the risk of potential approach related injuries to the esophagus, carotid artery, or recurrent laryngeal nerve. Additional benefits of posterior decompression include avoidance of instrumentation, which represents an increased healthcare cost, as well as potential long-term risks of adjacent-level pathologies or device failures. A traditional open posterior cervical approach has the potential to cause significant postoperative pain due to dissection of the paraspinal musculature and the potential for disrupting the posterior tension band with inadvertent injury to the interspinous ligaments. Such disadvantages are reduced by utilizing the minimally invasive technique where a small tubular working channel is placed through a muscle splitting technique via a paramedian approach. This technique minimizes the need for muscle stripping, and thus decreases postoperative functional and structural disturbance. Discectomy in this case can also be safely performed with minimal retraction at the axilla of the nerve root. Additionally, this approach can be utilized in an ambulatory setting, which coupled with the lack of any additional instrumentation helps contribute to the overall healthcare cost savings of such a procedure. This video describes how the minimally invasive posterior cervical discectomy can be effectively and safely performed in this illustrative case. The patient consented to the procedure and publication.

The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture.

ObjectiveTo evaluate the clinical outcome of manual reduction combined with pedicle fixation through Wiltse paraspinal approach (WPA) in the treatment of thoracolumbar fractures.MethodsFrom May 2017 to May 2019, 48 thoracolumbar fractures patients without neurological symptoms were enrolled in this study. Forty‐eight patients were randomly divided into two groups based on the different surgical treatment. Group 1 was manual reduction combined with pedicle screw fixation through Wiltse paraspinal approach treatment group. Group 2 was pedicle screw fixation through traditional posterior approach treatment group. The operation time (OT), intraoperative blood loss (BL), postoperative drainage (PD), time of brace (TB) and the cobb angle recovery of the injured kyphosis in the prone position were obtained and compared between the two groups, respectively. Comparison of cobb angle changes, serum creatine kinase (CK) level, pain visual analogue score (VAS), Oswestry disability index (ODI), and multifidus cross‐sectional (MCS) area changes were achieved between the two groups, respectively.ResultsForty‐eight patients were enrolled in this study and each group had 24 patients. There was no significant difference between the two groups in patient's age, height, weight, and body mass index (BMI). There were 20 males and four females in group 1. The mean age, height, weight, and BMI of patients were 61.99 ± 11.00 years (range, 42–75 years), 175.21 ± 4.49 cm, 76.71 ± 4.87 kg, and 24.98 ± 1.03 kg/m2 in group 1, respectively. Group 2 had 18 males and six females, and the mean age, height, weight, and BMI of patients were 57.95 ± 9.22 years (range, 44–77 years), 176.37 ± 4.56 cm, 77.42 ± 4.61 kg, and 24.87 ± 1.10 kg/m2 in group 2, respectively. The mean bleeding volume of group 1 was significantly less than group 2 (64.13 ± 9.77 ml and 152.13 ± 10.73 ml, respectively) (P < 0.05). The mean operation time, postoperative drainage, and time of brace were 62.95 ± 9.80 min, 66.25 ± 12.75 ml, and 3.62 ± 0.97 days in group 1, respectively, and they were significantly better than those of group 2 (69.29 ± 6.82min, 162.96 ± 14.55ml and 7.88 ± 1.94 days, respectively) (P < 0.05). The mean multifidus cross‐sectional area was significantly smaller than per‐operation after surgery in two groups (P < 0.05). The mean creatine kinase of group 1 was 403.13 ± 39.78 U/L and 292.12 ± 45.81 U/L at 1 and 3 days after surgery, respectively, which was significantly smaller than those in group 2 (654.25 ± 53.13 U/L and 467.67 ± 44.25 U/L, respectively) (P < 0.05). The Oswestry disability index of group 1 were significantly better than those in group 2 especially at 1 month and final follow‐up after surgery (P < 0.05). Moreover, group 1 also had better outcomes in postoperative Cobb angle change than those in group 2, with significant difference on intra‐operation, 1 day and 1 month post‐operation (P < 0.05).ConclusionIn short, this operation is suitable for thoracolumbar fractures without neurologic symptoms. Preoperative manual reduction had advantages of restoring the height of injured vertebrae. Wiltse intermuscular approach can reduce intraoperative blood loss, shorten operation time, and reduce paraspinal muscle damage. Using the traditional posterior approach, it is easy for surgeons to grasp this technique and it should be recommended as conforming with the minimally invasive approach of recent years.

Incidence of adjacent-segment surgery following stand-alone lateral lumbar interbody fusion.

Adjacent-segment disease (ASD) requiring operative intervention is a relatively common long-term consequence of lumbar fusion surgery. Although the incidence of ASD requiring reoperation is well described for traditional posterior lumbar approaches (2.5%-3.9% per year), it remains poorly characterized for stand-alone lateral lumbar interbody fusion (LLIF). In this study, the authors report their institutional experience with ASD requiring reoperation after LLIF over an extended follow-up period of 4 years. Medical records were reviewed for 276 consecutive patients who underwent stand-alone LLIF by a single surgeon for degenerative spinal disorders. Inclusion criteria (single-stage, stand-alone LLIF without posterior supplementation, with no prior lumbar instrumentation, and a minimum of 4 years of follow-up) were met by 182 patients, who were analyzed for operative ASD incidence (per-year rate), demographics, and Oswestry Disability Index (ODI) score. Operative ASD was strictly defined as new-onset pathology following index surgery at directly adjacent levels to the prior construct. Operative, rather than symptomatic or radiographic, ASD was analyzed to provide a consistent and impactful endpoint while avoiding retrospective diagnosis. The study cohort of 182 patients had an operative ASD rate of 3.3% (n = 6 procedures) over 4 years of follow-up, for an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI 0.67%-1.09%) per year. In comparing patients with operative ASD with those without, there were no significant differences in mean age (53.7 vs 56.2 years), male sex (33.3% vs 44.9%), smoking status (16.7% vs 25.0%), or number of levels fused (mean 1.33 vs 1.46). The operative ASD cohort had a greater mean BMI (37.3 vs 30.2, p < 0.01). Operative ASD patients had lower baseline ODI scores (33.8 vs 48.3, p = 0.02); however, no difference was observed in ODI at 6 weeks (34.0 vs 39.0) or 3 months (16.0 vs 32.8) postoperatively. The incidence of ASD in LLIF for degenerative lumbar etiologies in this cohort was 0.88% (95% CI 0.67%-1.09%) per year. Meanwhile, the reported reoperation rates for ASD in posterior spinal approaches was 2.5% to 3.9% per year, which implies that LLIF may be preferable for well-selected patients.

Lateral access techniques for degenerative conditions of the spine

Operative approaches for degenerative conditions of the spine include traditional posterior approaches and a newer generation of lateral approaches. These operative corridors have their roots in anterior lumbar fusion and modifications have evolved to include lateral and oblique lumbar interbody fusion. The principal advantages of lateral approaches are that they are minimally invasive, less disruptive, and provide greater access to the disc space, thus allowing for larger cage placement and theoretically greater indirect foraminal decompression with lower rates of subsidence. We describe the anterior, lateral, and oblique lumbar interbody fusion approaches, with particular emphasis on surgical techniques and complications.

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

IntroductionOver the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures. MethodsIn a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively. ResultsNo differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1). ConclusionsThe results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.