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ABSTRACT: Sixty-two consecutive patients undergoing anterior lumbar revision surgery from February 2000 to September 2007 were evaluated for approach strategies and complications.
To determine the incidence of complications in these patients and to make recommendations on future revisions based on the results obtained.
Only 2 articles exist in the literature that address this situation and they have widely varying results in a small number of patients. This larger series may help give more certainty to the expectations for complications in patients undergoing revision anterior lumbar surgery.
A concurrent database was maintained on these 62 consecutive patients. Preoperative strategies were evaluated and complications were tabulated as they occurred and later analyzed to arrive at recommendations for future similar cases.
Twenty-three patients had the same level revised and 39 patients had adjacent levels operated on. There were 3 venous injuries (4.8%), 3 arterial injuries (4.8%), and 1 ureteral injury (1.6%). All 3 arterial injuries occurred while approaching L3-L4 after L4 to S1 prior fusion or disc replacement. All 3 venous injuries and the ureteral injury occurred while approaching a previously operated level or levels. Six of these patients had the injuries repaired and the procedures completed with full recovery. One L5-S1 revision had the procedure aborted after a venous injury. There were no deaths.
Although the incidence of complications in revisions is much greater than for index cases, the actual percentage of venous, arterial, and ureteral complications is certainly acceptable for patients who must have this type of surgery. Only very experienced access surgeons should attempt revision surgery.
Spine 08/2008; 33(15):1662-7. · 2.16 Impact Factor
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ABSTRACT: To determine the incidence of left iliac artery thrombosis (LIAT), a prospective database was maintained on 1315 patients undergoing anterior lumbar surgery (ALS) between August 1997 and December 2002. All had distal pulse evaluation preoperatively. In the last 629 cases pulse oxymetry was used to monitor the distal circulation during and after surgery. Patients with pulse deficits or evidence of ischemia after surgery were further analyzed. Six patients were identified with LIAT (0.45%). Five were females and one was male, with ages ranging from 35 to 56 years. All had exposure at the L4-5. Five were diagnosed at surgery and one in the recovery room after posterior surgery. All except one had strong, palpable preoperative pulses. Pulse oxymetry confirmed the diagnosis in two patients, in whom it was not clinically evident. Four had successful thrombectomy; one had a femoro-femoral bypass and one had an axillo-femoral bypass. Two developed compartment syndrome. None had calcifications on preoperative X-rays. LIAT is an uncommon complication of ALS. Early identification and management can avoid long-term complications. Pulse oxymetry helps in its timely identification. Patients undergoing exposure at L4-5 and females are at greater risk.
Annals of Vascular Surgery 02/2004; 18(1):48-51. · 0.99 Impact Factor
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ABSTRACT: With the number of anterior lumbar procedures expected to increase significantly over the next few years, it is important for spine surgeons to have a good understanding about the incidence of vascular complications during these operations.
To determine the incidence of vascular injury in 1,315 consecutive cases undergoing anterior lumbar surgery at various levels from L2 to S1.
Patients undergoing anterior lumbar surgery were studied.
A total of 1,310 consecutive patients undergoing 1,315 anterior lumbar procedures between August 1997 and December 2002 were included in the study.
All patients were evaluated for incidence of vascular injury during and immediately after surgery.
A concurrent database was maintained on all these cases. All the patients had distal pulse evaluation preoperatively. Patients with venous injuries were further analyzed to determine location and extent of injury, amount of blood loss, completion of the procedure and postoperative sequelae. Patients with pulse deficits or evidence of ischemia during or immediately after surgery were further analyzed in particular in relation to demographic, preoperative variables and management.
Six patients were identified as having left iliac artery thrombosis (0.45%), and 19 had major vein lacerations (1.4%).
This study shows that the incidence of vascular injury is relatively low (25 in 1,315 or 1.9%). Because only five of these patients experienced significant sequelae from the approach, it appears that anterior lumbar surgery is quite safe, although it must be carried out with utmost respect for the vessels to avoid possible catastrophic outcomes.
The Spine Journal 01/2004; 4(4):409-12. · 3.36 Impact Factor
The Spine Journal 09/2003; 3(5):93-93. · 3.36 Impact Factor
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ABSTRACT: The use of interbody fusion cages as a treatment for degenerative disc disease has become widespread. Low-profile cages have been developed to allow a closer fit when implanting bilateral cages in patients with smaller vertebral bodies. Some surgeons feel the open design also allows better bone contact and visualization. This is particularly true when two low-profile cages are used adjacent to one another. Because of the open design of low-profile interbody fusion cages, there has been concern regarding such issues as subsidence, lordosis and fusion rates.
This retrospective review of paired bilateral reduced profile interbody fusion cages was completed to assess changes in subsidence, lordosis and fusion. As a secondary goal, patient outcomes were measured to determine overall health since surgery and the patient's satisfaction with the spine surgery, in an attempt to assess the effect of the outcome variables cited supra.
This was a retrospective evaluation of patients who underwent anterior lumbar interbody fusion with low-profile interbody fusion cages.
Seventy-one consecutive patients who underwent bilateral implantation of low-profile interbody fusion cages were evaluated.
A patient self-evaluation, which included a Short Form (SF)-36 and questions regarding patient satisfaction were administered to patients who were at least 1 year postoperative. Subsidence and lordosis measurements were completed. Fusion was assessed by the operating surgeon.
Low-profile interbody fusion cages (BAK/Proximity, Centerpulse Spine-Tech, Inc., Minneapolis, MN) were implanted bilaterally in at least one level from L3-L4 to L5-S1. Most patients had degenerative disc disease with leg and back pain that was not responsive to conservative treatment and demonstrated segmental instability or collapse. A small percentage of patients had either a degenerative spondylolisthesis (7.0%) or an isthmic spondylolisthesis (4.2%). Autograft harvested from the iliac crest was used in all cases. Demographic, surgical and follow-up data were retrospectively collected from patient charts. A clinical outcome questionnaire that included an SF-36 as well as questions regarding patient satisfaction was either mailed to each patient who was at least 1 year postsurgery or given to patients to complete at their 1-year visit. Patients were routinely followed radiographically before surgery, immediately after surgery and at 3, 6, 12 and 24 months after surgery. Fusion was assessed by the operating surgeon using lateral radiographs often in conjunction with a thin-slice computed tomography (CT) scan. Criteria for a successful fusion were lack of motion, anterior bridging bone and lack of lucencies on flexion/extension X-rays and/or contiguous bone through the cage using a thin-cut sagittal CT scan. Lateral X-rays on each patient were also measured for subsidence and lordosis changes.
A total of 71 patients (45 men, 26 women) with a mean age of 43.4 years (range, 25 to 74) were evaluated. Thirty-six percent of the patients were smokers, and 96% were worker's compensation patients. Thirty-two percent of the patients had previous lumbar surgery. A total of 100 operative levels were evaluated. There were 45 one-level, 23 two-level and three three-level cases. Forty-nine percent were level L5-S1, 43% were L4-L5 and 8% were L3-L4. The mean duration of symptoms was 31.5 months. Mean surgical time, mean blood loss and mean hospital stay were 139 minutes, 186 cc and 3.34 days, respectively. There were no intraoperative or postoperative complications attributable to the construct and no cases of cage migration or collapse. Patients who were at least 1-year postsurgery and had follow-up X-rays or had undergone a CT scan at this time point were evaluated for fusion status. Sixty-three patients were assessed for fusion. Fifty-four (86%) of these patients were determined to have a solid fusion. Mean time to fusion was 10 months. Fusion was assessed as solid only if all operative levels were fully fused. Mean subsidence of the anterior region was 1.97 mm, whereas the mean subsidence of the posterior region was 0.82 mm. Lordosis was unchanged at all surgical levels with mean lordosis in L3-L4 decreasing only slightly from 13 degrees before surgery to 12 degrees after surgery. L4-L5 and L5-S1 showed only slight increases in lordosis changing from 17 to 18 degrees at L4-L5 and from 17 to 19 degrees at L5-S1. These changes were not statistically significant. The clinical outcome questionnaires had a return rate of 68%. Of the 48 patients who completed the questionnaire, 75% responded that they were happy with the surgical results and would definitely recommend the surgery to a friend. Sixty-seven percent agreed that surgery met their expectations or that surgery improved their condition enough that they would go through it again for the same outcome. The results of the SF-36 portion of the survey revealed that the physical and mental composite scores were within normal range of the US population that has experienced back pain or sciatica.
Bilateral implantation of low-profile cages in this patient population led to satisfactory outcomes. Subsidence and changes in lordosis were minimal. Fusion rates were good, especially for one-level cases. Patient satisfaction was relatively high, considering the population consisted of 96% worker's compensation cases. With proper surgical technique, bilateral low-profile cages can be used effectively to treat patients with degenerative disc disease.
The Spine Journal 01/2003; 3(5):377-87. · 3.36 Impact Factor