Mini-open approach to the spine for anterior lumbar interbody fusion: description of the procedure, results and complications

Abstract

Background context: Since the introduction of threaded devices in the mid-1990s, anterior lumbar interbody fusion (ALIF) has become a staple in the armamentarium of the spine surgeon. The procedure, however, is heavily dependent on the ability of the approach surgeon to provide exposure quickly and safely in view of a reported incidence of vascular injury as high as 15% and 2.3% incidence of retrograde ejaculation.

Purpose: This study describes a mini-open approach to the lumbar spine and discusses the results and the complications seen.

Study design/setting: The study was designed to evaluate patients for possible complications of the approach while they were in the hospital undergoing ALIF. They were also followed for 6 months after the operation.

Patient sample: A total of 686 approaches to the lumbar spine performed on 684 patients between August 1997 and December 2000 were reviewed concurrently and retrospectively.

Outcome measures: All complications of the approach were reported. These included vascular injury, retrograde ejaculation, deep vein thrombosis (DVT), pulmonary emboli, infection, wound disruption/hernia, ileus, hematoma, myocardial infarction, stroke, peripheral ischemia, rectus muscle paralysis, aborted cases and death.

Methods: The patients were observed in the perioperative period and for 6 months postoperatively to determine the occurrence of complications related to the approach. The data collected included age, weight, gender, levels approached, time of completion of the approach, size of incision and complications.

Results: There were six arterial injuries (0.8%), six venous injuries (0.8%) and one instance of retrograde ejaculation (0.1%). In addition, there were seven cases that developed DVT (two ileofemoral and five calf-popliteal, 1.0%), four cases of ileus lasting more than 3 days (0.6%), three wound infections above the fascia (0.4%), two hernias and two compartment syndromes. There was one myocardial infarction and one death. No rectus muscle paralysis occurred.

Conclusions: This experience suggests that a well-planned small incision that preserves the musculature can be performed quickly and safely to allow the spine surgeon adequate access to the anterior lumbar spine. The learning curve, however, can be high even for experienced surgeons.