General Session: Lumbar
Presented by: J. Zigler - View Audio/Video Presentation (Members Only)
J. Zigler(1), J. Shivers(1), R. Guyer(1), D. Ohnmeiss(2)
(1) Texas Back Institute, Plano, TX, United States
(2) Texas Back Institute Research Foundation, Plano, TX, United States
Introduction: Anterior exposure to the lumbar spine offers several benefits, including reduced chance of direct neural injury, avoiding damage to the posterior musculature, direct access to remove disc tissue to prepare a fusion bed, restore alignment, and implantation total disc replacements (TDRs). However, it also carries risks of significant complications such as injury to vascular structures, and/or injury to the bowels, ureters, or bladder. The purpose of this study was to investigate the complication rate associated with the anterior retroperitoneal approach to the lumbar spine, and explore possible related factors.
Methods: The study was based on a consecutive series of 2,881 patients who underwent anterior lumbar spine surgery during the six year period from January 1, 2009 to December 31, 2014. All cases were performed by surgeons associated with a multi-site spine specialty clinic. A comprehensive surgery log has been maintained of all cases performed by the surgical group and is used for quality assurance analysis. All operative notes were reviewed by research staff and intra-operative complications recorded. Post-operative complications were recorded at post-operative visits. The surgery log was searched to identify anterior approach related complications. The types of surgeries included all anterior lumbar interbody fusion (with or without combined posterior fusion) and lumbar total disc replacement. Complications such as retrograde ejaculation were not reported since these are not reliably identified without specific evaluations, beyond the scope of routine clinical follow-up and the quality assurance records.
Results: The overall occurrence of anterior approach related complications was 1.32% (38 incidences in 2,881 cases). There were 31 vascular injuries. The majority (27) were repaired intra-operatively without further complication. One patient was transferred to a specialized center for care and later recovered, one required a thrombectomy and recovered uneventfully, and one patient had a vascular tear repaired intra-operatively, but later died of a pulmonary embolus. There were 5 bowel/bladder complications (including one case each of bowel injury, bladder injury, ureteral injury, combined ureter and bowel obstruction, and one patient who had a bowel occlusion that later resulted in death). Additionally, there was one case of peritoneal injury and one rectus sheath hematoma. The rates of approach complications did not vary by access surgeon or by spine surgeon. The complication rate was significantly greater for 3-level procedures (p< 0.05), but not when comparing 1- vs. 2-level cases. When analyzing the occurrences over time, there were two periods of increased rates, but no explanatory factors were identified.
Conclusions: The results of this study suggest that the anterior approach to the lumbar spine is generally safe. Rare catastrophic complications can occur, even when the exposures are performed by access and spine surgeons with many years of experience with this approach. Surgeons and patients should be aware of the complication risk, and should be prepared to address intra-operative anterior approach complications (especially incidental vascular injuries) to minimize morbidity.