Anterior longitudinal ligament release using the minimally invasive lateral retroperitoneal transpsoas approach: a cadaveric feasibility study and report of 4 clinical cases

2012 ◽  
Vol 17 (6) ◽  
pp. 530-539 ◽  
Author(s):  
Armen R. Deukmedjian ◽  
Tien V. Le ◽  
Ali A. Baaj ◽  
Elias Dakwar ◽  
Donald A. Smith ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Lumbar Lordosis ◽  
Lumbar Disc ◽  
Vena Cava ◽  
Surgical Anatomy ◽  
Sagittal Imbalance ◽  
Anterior Longitudinal Ligament ◽  
Vertebral Column Resection ◽  
Transpsoas Approach ◽  
Clinical Cases

Object Traditional procedures for correction of sagittal imbalance via shortening of the posterior column include the Smith-Petersen osteotomy, pedicle subtraction osteotomy, and vertebral column resection. These procedures require wide exposure of the spinal column posteriorly, and may be associated with significant morbidity. Anterior longitudinal ligament (ALL) release using the minimally invasive lateral retroperitoneal approach with a resultant net lengthening of the anterior column has been performed as an alternative to increase lordosis. The objective of this study was to demonstrate the feasibility and early clinical experience of ALL release through a minimally invasive lateral retroperitoneal transpsoas approach, as well as to describe its surgical anatomy in the lumbar spine. Methods Forty-eight lumbar levels were dissected in 12 fresh-frozen cadaveric specimens to study the anatomy of the ALL as well as its surrounding structures, and to determine the feasibility of the technique. The lumbar disc spaces and ALL were accessed via the lateral transpsoas approach and confirmed with fluoroscopy in each specimen. As an adjunct, 4 clinical cases of ALL release through the minimally invasive lateral retroperitoneal transpsoas approach were reviewed. Operative technique, results, complications, and early outcomes were assessed. Results In the cadaveric study, sectioning of the ALL proved to be feasible from the minimally invasive lateral retroperitoneal transpsoas approach. The structures at most immediate risk during this procedure were the aorta, inferior vena cava, iliac vessels, and sympathetic plexus. The mean increase in segmental lumbar lordosis per level of ALL release was 10.2°, while global lumbar lordosis improved by 25°. Each level of ALL release took 56 minutes and produced 40 ml of blood loss on average. Visual analog scale and Oswestry Disability Index scores improved by 9 and 35 points, respectively. There were no cases of hardware failure, and as of yet no complications to report. Conclusions This initial experience suggests that ALL release through the minimally invasive lateral retroperitoneal transpsoas approach may be feasible, allows for improvement of lumbar lordosis without the need of an open laparotomy/thoracotomy, and minimizes the tissue disruption and morbidity associated with posterior osteotomies.

Anterior Longitudinal Ligament Release From the Minimally Invasive Lateral Retroperitoneal Transpsoas Approach: Technical Note

2016 ◽  
Vol 12 (3) ◽  
pp. 214-221 ◽  
Author(s):  
Joshua M Beckman ◽  
Nicola Marengo ◽  
Gisela Murray ◽  
Konrad Bach ◽  
Juan S Uribe
Keyword(s):  
Blood Loss ◽  
Minimally Invasive ◽  
Lumbar Lordosis ◽  
Adult Spinal Deformity ◽  
Vascular Complications ◽  
Deformity Correction ◽  
Anterior Longitudinal Ligament ◽  
Global Improvement ◽  
Transpsoas Approach ◽  
Indirect Decompression

Abstract BACKGROUND The technique for minimally invasive anterior longitudinal ligament release is a major advancement in lateral access surgery. This method provides hypermobility of lumbar segments to allow for aggressive lordosis restoration while maintaining the benefits of indirect decompression and minimally invasive access. OBJECTIVE To provide video demonstration of the lateral retroperitoneal transpsoas approach with anterior longitudinal ligament sectioning. METHODS A detailed surgical technique of the minimally invasive anterior column release is described and illustrated in an elderly patient with adult spinal deformity and low back pain (visual analog scale, 8 of 10) refractory to conservative measures. The 3-foot standing radiographs demonstrated a lumbar lordosis of 54.4°, pelvic incidence of 63.7°, and pelvic tilt of 17.5°. Computed tomography and magnetic resonance imaging showed generalized lumbar spondylosis and degenerative disc changes from L2 to L5. RESULTS The patient underwent a multilevel minimally invasive deformity correction with an anterior longitudinal ligament release at the L3/L4 level through the lateral retroperitoneal transpsoas approach. Lumbar lordosis increased from 54.4° to 77° with a global improvement in sagittal vertical axis from 4.37 cm to 0 cm. Total blood loss was less than 25 mL, and there were no major neurological or vascular complications. CONCLUSION The anterior longitudinal ligament release using the minimally invasive lateral approach allows for deformity correction without the morbidity and blood loss encountered by traditional open posterior approaches. However, the risk of major vascular/visceral complication warrants only experts in minimally invasive lateral surgery to attempt this technique.

Lordosis restoration after anterior longitudinal ligament release and placement of lateral hyperlordotic interbody cages during the minimally invasive lateral transpsoas approach: a radiographic study in cadavers

2012 ◽  
Vol 17 (5) ◽  
pp. 476-485 ◽  
Author(s):  
Juan S. Uribe ◽  
Donald A. Smith ◽  
Elias Dakwar ◽  
Ali A. Baaj ◽  
Gregory M. Mundis ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Lumbar Lordosis ◽  
Anterior Longitudinal Ligament ◽  
Maximum Increase ◽  
Transpsoas Approach ◽  
Before And After ◽  
Fresh Frozen ◽  
The Mean ◽  
Segmental Lordosis ◽  
Cobb Method

Object In the surgical treatment of spinal deformities, the importance of restoring lumbar lordosis is well recognized. Smith-Petersen osteotomies (SPOs) yield approximately 10° of lordosis per level, whereas pedicle subtraction osteotomies result in as much as 30° increased lumbar lordosis. Recently, selective release of the anterior longitudinal ligament (ALL) and placement of lordotic interbody grafts using the minimally invasive lateral retroperitoneal transpsoas approach (XLIF) has been performed as an attempt to increase lumbar lordosis while avoiding the morbidity of osteotomy. The objective of the present study was to measure the effect of the selective release of the ALL and varying degrees of lordotic implants placed using the XLIF approach on segmental lumbar lordosis in cadaveric specimens between L-1 and L-5. Methods Nine adult fresh-frozen cadaveric specimens were placed in the lateral decubitus position. Lateral radiographs were obtained at baseline and after 4 interventions at each level as follows: 1) placement of a standard 10° lordotic cage, 2) ALL release and placement of a 10° lordotic cage, 3) ALL release and placement of a 20° lordotic cage, and 4) ALL release and placement of a 30° lordotic cage. All four cages were implanted sequentially at each interbody level between L-1 and L-5. Before and after each intervention, segmental lumbar lordosis was measured in all specimens at each interbody level between L-1 and L-5 using the Cobb method on lateral radiography. Results The mean baseline segmental lordotic angles at L1–2, L2–3, L3–4, and L4–5 were –3.8°, 3.8°, 7.8°, and 22.6°, respectively. The mean lumbar lordosis was 29.4°. Compared with baseline, the mean postimplantation increase in segmental lordosis in all levels combined was 0.9° in Intervention 1 (10° cage without ALL release); 4.1° in Intervention 2 (ALL release with 10° cage); 9.5° in Intervention 3 (ALL release with 20° cage); and 11.6° in Intervention 4 (ALL release with 30° cage). Foraminal height in the same sequence of conditions increased by 6.3%, 4.6%, 8.8% and 10.4%, respectively, while central disc height increased by 16.1%, 22.3%, 52.0% and 66.7%, respectively. Following ALL release and placement of lordotic cages at all 4 lumbar levels, the average global lumbar lordosis increase from preoperative lordosis was 3.2° using 10° cages, 12.0° using 20° cages, and 20.3° using 30° cages. Global lumbar lordosis with the cages at 4 levels exhibited a negative correlation with preoperative global lordosis (10°, R = −0.756; 20°, −0.730; and 30°, R = −0.437). Conclusions Combined ALL release and placement of increasingly lordotic lateral interbody cages leads to progressive gains in segmental lordosis in the lumbar spine. Mean global lumbar lordosis similarly increased with increasingly lordotic cages, although the effect with a single cage could not be evaluated. Greater global lordosis was achieved with smaller preoperative lordosis. The mean maximum increase in segmental lordosis of 11.6° followed ALL release and placement of the 30° cage.

scholarly journals Early Outcomes of Minimally Invasive Anterior Longitudinal Ligament Release for Correction of Sagittal Imbalance in Patients with Adult Spinal Deformity

2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Armen R. Deukmedjian ◽  
Elias Dakwar ◽  
Amir Ahmadian ◽  
Donald A. Smith ◽  
Juan S. Uribe
Keyword(s):  
Minimally Invasive ◽  
Spinal Deformity ◽  
Lumbar Lordosis ◽  
Adult Spinal Deformity ◽  
Early Experience ◽  
Sagittal Imbalance ◽  
X Rays ◽  
Anterior Longitudinal Ligament ◽  
Average Hospital ◽  
Estimated Blood Loss

The object of this study was to evaluate a novel surgical technique in the treatment of adult degenerative scoliosis and present our early experience with the minimally invasive lateral approach for anterior longitudinal ligament release to provide lumbar lordosis and examine its impact on sagittal balance.Methods. All patients with adult spinal deformity (ASD) treated with the minimally invasive lateral retroperitoneal transpsoas interbody fusion (MIS LIF) for release of the anterior longitudinal ligament were examined. Patient demographics, clinical data, spinopelvic parameters, and outcome measures were recorded.Results. Seven patients underwent release of the anterior longitudinal ligament (ALR) to improve sagittal imbalance. All cases were split into anterior and posterior stages, with mean estimated blood loss of 125 cc and 530 cc, respectively. Average hospital stay was 8.3 days, and mean follow-up time was 9.1 months. Comparing pre- and postoperative 36′′ standing X-rays, the authors discovered a mean increase in global lumbar lordosis of 24 degrees, increase in segmental lumbar lordosis of 17 degrees per level of ALL released, decrease in pelvic tilt of 7 degrees, and decrease in sagittal vertical axis of 4.9 cm. At the last followup, there was a mean improvement in VAS and ODI scores of 26.2% and 18.3%.Conclusions. In the authors’ early experience, release of the anterior longitudinal ligament using the minimally invasive lateral retroperitoneal transpsoas approach may be a feasible alternative in correcting sagittal deformity.

Endovascular repair of arteriovenous fistula after microendoscopic discectomy and lamino-foraminotomy

Vascular ◽  
2014 ◽  
Vol 23 (1) ◽  
pp. 93-98 ◽  
Author(s):  
Hunter Cape ◽  
Dahlia Y Balaban ◽  
Michael Moloney
Keyword(s):  
Minimally Invasive ◽  
Inferior Vena ◽  
Common Iliac Artery ◽  
Lumbar Disc ◽  
Vena Cava ◽  
Subsequent Work ◽  
Microendoscopic Discectomy ◽  
Endovascular Approach ◽  
Work Up ◽  
High Output

The last two decades have seen increasing adoption of minimally invasive approaches to lumbar disc herniation management. As with many new advances in surgery, the risk profile of these contemporary approaches has yet to be well defined. We present the case of a 32-year-old man who presented with decreasing exercise tolerance over a 6-month period after microendoscopic lumbar discectomy and lamino-foraminotomy. Subsequent work-up revealed a large fistula between his right common iliac artery and inferior vena cava, resulting in high-output cardiac failure. This was managed well with an endovascular approach. This case highlights the importance of complication cognizance for patients who undergo minimally invasive lumbar disc surgery, as serious consequences can occur.

Release of Anterior Longitudinal Ligament in Setting of Unfavorable Vascular Anatomy for Anterior Column Realignment—Technical Note: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (2) ◽  
pp. E189-E189
Author(s):  
Jakub Godzik ◽  
Corey T Walker ◽  
Alexander C Whiting ◽  
Randall J Hlubek ◽  
Juan S Uribe ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Surgical Techniques ◽  
Technical Note ◽  
Anterior Column ◽  
Preoperative Imaging ◽  
Invasive Technique ◽  
Anterior Longitudinal Ligament ◽  
Transpsoas Approach ◽  
Patient Consent ◽  
Flat Back

Abstract Anterior column realignment (ACR) with anterior longitudinal ligament (ALL) release from a lateral transpsoas approach is increasingly being used as a minimally invasive technique to restore lordosis. Safe execution requires a plane between the ALL and the anterior vasculature. An unfavorable plane on preoperative imaging is a contraindication to using the technique. We describe a patient undergoing multistage minimally invasive correction of a flat-back deformity who had an unfavorable plane between the ALL and vasculature at L4-5. Patient consent was provided, and Institutional Review Board approval was not required. To safely complete the ALL release and ACR, we elected to sharply incise the lateral aspect of the ligament at L4-5 with direct control of the vessels during the anterior approach for an L5-S1 anterior lumbar interbody fusion. We then moved to the lateral transpsoas approach and used controlled distraction techniques to complete the ALL release and then to complete the ACR in a standard fashion. We ultimately achieved excellent realignment with correction of the patient's flat-back deformity using minimally invasive surgical techniques while minimizing vascular risk. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Extreme-lateral, minimally invasive, transpsoas approach for the treatment of far-lateral lumbar disc herniation

2010 ◽  
Vol 12 (4) ◽  
pp. 347-350 ◽  
Author(s):  
Ricky Madhok ◽  
Adam S. Kanter
Keyword(s):  
Minimally Invasive ◽  
Lumbar Disc Herniation ◽  
Disc Herniation ◽  
Lumbar Disc ◽  
Retroperitoneal Approach ◽  
Transpsoas Approach ◽  
Disc Herniations ◽  
Far Lateral

The authors present 2 cases of far-lateral lumbar disc herniations treated surgically via an extreme-lateral transpsoas approach. The procedure was performed using the MaXcess minimally invasive retractor system to access and successfully remove the disc fragments without complication. To the authors' knowledge, these are the first reported cases of using a minimally invasive retroperitoneal approach for the treatment of far-lateral disc herniations.

Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study

2014 ◽  
Vol 20 (5) ◽  
pp. 515-522 ◽  
Author(s):  
Jotham C. Manwaring ◽  
Konrad Bach ◽  
Amir A. Ahmadian ◽  
Armen R. Deukmedjian ◽  
Donald A. Smith ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Cobb Angle ◽  
Spinal Deformity ◽  
Lumbar Lordosis ◽  
Interbody Fusion ◽  
Adult Spinal Deformity ◽  
Spinal Instrumentation ◽  
Sagittal Imbalance ◽  
Lumbar Interbody Fusion ◽  
Spinopelvic Parameters

Object Minimally invasive (MI) fusion and instrumentation techniques are playing a new role in the treatment of adult spinal deformity. The open pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO) are proven segmental methods for improving regional lordosis and global sagittal parameters. Recently the MI anterior column release (ACR) was introduced as a segmental method for treating sagittal imbalance. There is a paucity of data in the literature evaluating the alternatives to PSO and SPO for sagittal balance correction. Thus, the authors conducted a preliminary retrospective radiographic review of prospectively collected data from 2009 to 2012 at a single institution. The objectives of this study were to: 1) investigate the radiographic effect of MI-ACR on spinopelvic parameters, 2) compare the radiographic effect of MI-ACR with PSO and SPO for treatment of adult spinal deformity, and 3) investigate the radiographic effect of percutaneous posterior spinal instrumentation on spinopelvic parameters when combined with MI transpsoas lateral interbody fusion (LIF) for adult spinal deformity. Methods: Patient demographics and radiographic data were collected for 36 patients (9 patients who underwent MI-ACR and 27 patients who did not undergo MI-ACR). Patients included in the study were those who had undergone at least a 2-level MI-LIF procedure; adequate preoperative and postoperative 36-inch radiographs of the scoliotic curvature; a separate second-stage procedure for the placement of posterior spinal instrumentation; and a diagnosis of degenerative scoliosis (coronal Cobb angle > 10° and/or sagittal vertebral axis > 5 cm). Statistical analysis was performed for normality and significance testing. Results Percutaneous transpedicular spinal instrumentation did not significantly alter any of the spinopelvic parameters in either the ACR group or the non-ACR group. Lateral MI-LIF alone significantly improved coronal Cobb angle by 16°, and the fractional curve significantly improved in a subgroup treated with L5–S1 transforaminal lumbar interbody fusion. Fifteen ACRs were performed in 9 patients and resulted in significant coronal Cobb angle correction, lumbar lordosis correction of 16.5°, and sagittal vertebral axis correction of 4.8 cm per patient. Segmental analysis revealed a 12° gain in segmental lumbar lordosis and a 3.1-cm correction of the sagittal vertebral axis per ACR level treated. Conclusions The lateral MI-LIF with ACR has the ability to powerfully restore lumbar lordosis and correct sagittal imbalance. This segmental MI surgical technique boasts equivalence to SPO correction of these global radiographic parameters while simultaneously creating additional disc height and correcting coronal imbalance. Addition of posterior percutaneous instrumentation without in situ manipulation or overcorrection does not alter radiographic parameters when combined with the lateral MI-LIF.

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