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Fig. 54.5 The skin incision is marked under X-ray control so that the
incision lies along the extended line of the intervertebral space. (With
permission of Aesculap AG, Tuttlingen, Germany)
K. Wiechert and U. Vieweg
Fig. 54.7 A blunt dissection is used to push the peritoneum away in a medial
direction, rst from the rear surface of the muscle and then from the lateral
abdominal wall. (With permission of Aesculap AG, Tuttlingen, Germany)
Fig. 54.6 Linear incision of the anterior fascia of the rectus abdominis
muscle. (With permission of Aesculap AG, Tuttlingen, Germany)
54.6.1.2 Anterior Pararectal Approach L2/3,
L3/4, L4/5
The anterior pararectus approach is considerably easier in
the upper lumbar region of the spine but carries a higher risk
of segmental denervation of the abdominal muscles.
Fig. 54.8 Ligation and dissection of the medial sacral vessels in the
bifurcation. (With permission of Aesculap AG, Tuttlingen, Germany)
• The muscle fascia is dissected longitudinally where the
muscles meet at the lateral margin of the rectus abdominis
muscle.
• A blunt instrument is used to push the peritoneum away from
the abdominal wall while monitoring the epigastric vessels.
• The ureter is mobilized and moved away from the operating site together with the peritoneum.
• The ventrolateral spine is exposed at the anterior margin
of the psoas muscle.
• The vessels supplying the neighboring segment are ligated
and dissected, including the ascending lumbar vein if the
54 Anterior Lumbar Interbody Fusion (ALIF) Using Bone or Cage
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a
a
b
b
c
Fig. 54.9 Placement of the retractor blades, (a) lateral view, (b) AP
view, (c) preferrable relation between retractors and the vascular
bifurcations
Fig. 54.10 (a) The neighboring segment vessels are ligated and dis-
sected, including the ascending lumbar vein for the approach to the
L4/5 segment. (b) Preferred retractor placement for exposure of anterior circumference of the disk space. (With permission of Aesculap AG,
Tuttlingen, Germany)
L4/5 segment is being approached, so that the major vessels can be mobilized to the opposite side (see Fig.54.10).
• The sympathetic nerve is mobilized in a lateral direction.
• Note: In the midline marking process, the lateral inclination of the operating table may have to be adjusted to
compensate for any possible turning of the patient caused
by retraction of the muscles and abdominal organs.
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Fig. 54.11 Splitting approach—each muscle layer is dissected in the
direction of its ber orientation. (With permission of Aesculap AG,
Tuttlingen, Germany)
54.6.1.3 Lateral Approaches
• In the lateral approach, skin marking of the disk space level
and the center of the disk space is recommended, with the
skin incision obliquely crossing the center of the disk space.
• A 5–8-cm skin incision is centered above the projection of
the center of the disk space in an oblique direction parallel
to the bers of the external oblique abdominal muscles.
• The lateral approach involves a blunt split of the three
abdominal wall muscle sheaths, blunt preparation down
to the psoas muscle, and exposure of the anterior edge of
the psoas muscle.
• Each muscle layer (external oblique, internal oblique,
transverse abdominal muscle) is dissected in the direction
of its ber orientation (see Fig.54.11).
• Care must be taken to preserve the branches of the intercostal nerves 10–12 as well as the iliohypogastric/ilioinguinal nerves, which occasionally cross the surgical eld
between the layers of the internal oblique and transverse
abdominal muscle.
• The transverse abdominal muscle should be split as far
as possible to avoid opening of the peritoneum. There is
more retroperitoneal fat tissue beneath the lateral part
of the transverse muscle. Moreover, the peritoneum
adheres more to the inner wall of the medial part of this
muscle.
• The retroperitoneal space is enlarged by careful, blunt
dissection with cottonoids and Langenbeck retractors.
• The psoas muscle is identied as a rst anatomical landmark (Fig.54.12).
• The paravertebral tissues including the ureter and the vascular bundle are gently retracted toward the midline using
the blunt hooks. They are incised and sharply dissected
from the lateral circumference of the disk space (see
Fig.54.13). Usually, the lateral border of the left common
vein can be identied.
K. Wiechert and U. Vieweg
Fig. 54.12 Identication of the psoas muscle. (With permission of
Aesculap AG, Tuttlingen, Germany)
Fig. 54.13 The paravertebral tissue, including the ureter and the vas-
cular bundle, is gently retracted from the midline using blunt hooks.
(With permission of Aesculap AG, Tuttlingen, Germany)
• Dissection should be performed very carefully from the
ventrolateral aspect of the vertebral bodies. The segmental vessels of the vertebral body inferior to the disk space
can be exposed (see Fig.54.14).
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Fig. 54.14 Exposure of the segment vessels of the vertebral body infe-
rior to the disk space
• The segmental vessels of the inferior vertebral bodies
need to be ligated with endoclips and then cut and dissected from the vertebral surface.
• However, dissection is rarely necessary at the L3/4 and L2/3
levels. At L4/5, the ascending lumbar vein may obstruct the
inferior lateral angle of the surgical eld and needs to be
ligated with endoclips and dissected (see Fig.54.15).
• Dissection should not be extended posterior to the pedicle
entrance in order to avoid irritation of the lumbar nerve
roots.
• The disk space level is veried under uoroscopic control.
• The spatial orientation of the disk space is then identied
by cutting the annulus brosus parallel to the vertebral
endplates.
54.6.2 Interbody Fusion andInstrumentation
Instrumentation is completely unlimited in the mini-ALIF
approach. Any intervertebral cages or bone grafts for spinal
fusion can be used without specic considerations relating to
the approach [3–5]. Any other type of anterior interbody
fusion, including those using homograft or allografts, should
be possible with this approach.
54.6.2.1 Interbody Fusion withAutologous Iliac
Bone Graft
• With a drill guide, the anterolateral cortex of the adjacent
vertebral bodies is drilled in a strictly vertical direction to
create the holes for the distraction screws.
Fig. 54.15 At L4/5, the ascending lumbar vein may obstruct the infe-
rior lateral angle of the surgical eld and needs to be ligated with endoclips and dissected. (With permission of Aesculap AG, Tuttlingen,
Germany)
• The entry point is about 5–8mm from the intervertebral
space at the lateral border of the anterior longitudinal
ligament.
• The drill has a safety range of 10mm and penetrates only
the anterolateral cortex of the vertebral body. Then specially designed anchoring screws are inserted (see
Fig.54.16).
• A retractor frame is put in place. A sharp muscle blade is
attached laterally to deect the psoas muscle, whereas a
blunt vascular blade is inserted medially to retract the retroperitoneal vessels (see Fig.54.17a, b).
• Discectomy and preparation of the graft bed. The endplates are carefully removed with chisels (see
Fig.54.18).
• The subchondral bone is smoothed with a high-speed drill
(see Fig.54.19).
• The height and depth of the iliac crest graft needed are
measured with sliding callipers (see Figs. 54.20 and
54.21).
• A tricortical bone graft is harvested through a separate
small incision over the lateral iliac crest on the same
side. The bone graft is also taken from the middle part of
the iliac crest. It is removed using a double saw blade,
which can be adjusted to the size of the bone graft. The
graft is removed with the help of a graft cutter.
• A small hole is drilled into the graft, which is then
mounted onto a graft holder and impacted into the intervertebral space (see Fig.54.22).
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K. Wiechert and U. Vieweg
a
Fig. 54.16 Insertion of specially designed anchoring screws. (With
permission of Aesculap AG, Tuttlingen, Germany)
54.6.2.2 Interbody Fusion withALIF Cage
Implantation
• The disk space is cleared using disk knives, rongeurs,
curettes, and bone curettes. Angled instruments are available
for the lateral approach. Then bone rasps are used to refresh
the cartilage endplates (see Figs.54.23 and 54.24).
• Determination of implant size using trial implants (see
Fig.54.25). Trial implants are available in heights from 9
to 19mm in 2-mm increments. The insertion instrument
and depth stop are assembled. Before the trial implant is
attached, the depth stop must be turned forward to the rst
line on the depth scale. The trial implant is inserted with
the T-handle, and the depth stop is set as appropriate for
the implant position. For easier removal of the trial
implant, we recommend that the T-handle be replaced
with a slap hammer.
• The cage can be lled with bone or bone replacement
material in a packing block. The second insertion instrument is preadjusted according to the dened depth stop
position. The cage is inserted and corrected with the
impactor if necessary (see Fig.54.26).
b
Fig. 54.17 Positioning of the retractor blades in the lateral (a) and AP
(b) view
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Fig. 54.18 Careful removal of the endplates with chisels. (With per-
mission of Aesculap AG, Tuttlingen, Germany)
Fig. 54.20 Intraoperative situation after discectomy with Miaspas
retractor in position. (With permission of Aesculap AG, Tuttlingen,
Germany)
Fig. 54.19 The subchondral bone is smoothed with a high-speed drill.
(With permission of Aesculap AG, Tuttlingen, Germany)
Fig. 54.21 Measurement of the height and depth of the iliac crest
graft. (With permission of Aesculap AG, Tuttlingen, Germany)
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K. Wiechert and U. Vieweg
Fig. 54.22 Impaction of the bone piece with a graft holder into the
intervertebral space. (With permission of Aesculap AG, Tuttlingen,
Germany)
54.6.2.3 Anterior andAnterolateral Plating
Various systems are available to stabilize the anterior or
anterolateral lumbar spine. They include plate-screw systems (e.g., TSLP, Synthes; MACS, Aesculap; Pyramid,
Medtronic), rod-screw systems (e.g., VentroFix, Synthes),
and cages with an integrated plate (e.g., SynFix, Synthes).
For a less invasive procedure, it is essential that a retractor
system (e.g., activ O, Aesculap; SynFrame, Synthes) be used
for anterior and anterolateral plating of the lumbar spine. The
preparation and xing of the retractor blades make instrumentation much easier. For example, the blades of the activ
O retractor are placed at the cranial and caudal ends of the
segment and xed with pins. The other blades hold the
abdominal viscera and the psoas muscle to the side (see
Fig. 54.23 Cleaning of the disk space using disk knives, rongeurs,
curettes, and bone curettes. Then bone rasps are used to refresh the
cartilage endplates. (With permission of Aesculap AG, Tuttlingen,
Germany)
Fig. 54.24 After discectomy, a distractor should be inserted horizon-
tally and then rotated. (With permission of Aesculap AG, Tuttlingen,
Germany)
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Fig. 54.25 Determination of
implant size using trial
implants. The trial implant is
inserted with the slap
hammer. (With permission of
Aesculap AG, Tuttlingen,
Germany)
Fig. 54.26 The cage is
inserted and corrected with
the impactor. (With
permission of Aesculap AG,
Tuttlingen, Germany)
403
Fig.54.27a, b). With the aid of the retractor blades, the psoas
muscle is pushed from ventral to dorsal. The authors do not
recommend direct entry through the psoas muscle as in the
transmuscular XLIF approach. The use of the TSLP
(Synthes) is made easier by temporary xation pins. The
appropriate plate is xed to the ventral spine with the pins.
After intraoperative X-ray checks of the position of the plate
with respect to the spine, the plate is anchored at a stable
angle using four screws [6–8]. The access route can be kept
smaller when cages with an integrated plate (SynFix,
Synthes; Topaz, Ulrich) are used. The operating time is
reduced, because some of the instrumentation steps are rendered unnecessary.
54.7 Tips andTricks
• A preoperative color-coded 3D CT angiogram is recommended in all cases where the vascular anatomy cannot
be precisely identied or where there seem to be anatomic
variations.
• Once the patient has been positioned, it is mandatory that
an X-ray check of the target level be carried out in two
planes prior to surgery.
• Sometimes, the operating table or its base obscures the
visual plane. A preoperative check after the nal tilt can
save trial-and-error X-rays during the operation, thereby
reducing radiation exposure for patient and surgeons.
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K. Wiechert and U. Vieweg
a
b
Fig. 54.27 (a–d) Ventrolateral plating of the lumbar spine using a retractor system (activ O, Aesculap). Retractor blades are positioned at the
cranial and caudal ends of the segment and xed with pins. The other blades hold the abdominal viscera and psoas muscle to the side
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