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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6033_Библиотеки_им_академика_М_И_Перельмана.pdf
32 Awake Lateral Lumbar Fusion
Postoperative AP and lateral radiograph of single- level
percutaneous awake lateral lumbar fusion
313
Two and a half years follow-up, solid fusion, and maintenance of intervertebral height. Percutaneous pedicle
screws can be placed from the lateral position or prone
position depending on surgeon preference
314
This technique has also been used successfully up to four
levels; however, patient tolerance and procedure duration
must be considered
X. Zhang and B. Gaynor
32 Awake Lateral Lumbar Fusion
4-year follow-up radiographs in a pain-free patient
315
316
X. Zhang and B. Gaynor
The technique described in this chapter has
been used in 32 conscious patients undergoing
lateral lumbar fusion with local anesthesia. In
29 of these cases, pedicle screw fi xation was
also performed. One patient occurred (1 week)
graft migration who requiring revision lumbar
interbody fusion from a posterior approach.
This technique has also been shown to be feasible for multilevel fusions. Three-level fusions
were performed in six patients (fi ve with scoliosis deformity); however, one case was converted to general anesthesia prior to posterior
fi xation. In the majority of cases (26/32),
fusion was indicated for instability in lumbar
stenosis. One case was converted to posterior
transforaminal interbody fusion when neurological responses caused us to abort the
procedure.
Part VI
Managing and Preventing Complications
Managing and Preventing Vascular Complications
Asdrubal Falavigna and Orlando Righesso Neto
3 3
33.1 Introduction
The anterior approach to the lumbar spine places
the patient at risk for a number of signifi cant
intraoperative and perioperative complications.
These complications include vascular injury
(1.3–15.6 %), damage to the abdominal organs
(<1 %), disruption of the sympathetic plexus
(1.7–13.3 %), and postoperative ileus (0.6–5.6 %)
[ 1 – 4 ]. Newer surgical techniques, innovation in
instruments, and precise radiological localization and guidance have been constantly
developed to minimize surgical risks, decrease
the hospital stay, and potentially improve
patient satisfaction [ 5 ].
The lateral approach to the lumbar spine is a
relatively novel method for performing minimally
invasive lateral interbody fusions. The lateral
approach allows the surgeon to perform discectomy, anterior longitudinal ligament release, interbody cage placement at the apophyseal ring where
A. Falavigna (*)
Department of Neurosurgery, Cell Therapy
Laboratory and Clinical Studies and Basic Models of
Spinal Disorders Laboratory , University of Caxias do
Sul (UCS) , Caxias do Sul , RS , Brazil
asdrubalmd@gmail.com
e-mail:
O. R. Neto
Department of Orthopedic, Cell Therapy Laboratory
and Clinical Studies and Basic Models of Spinal
Disorders Laboratory , University of Caxias do
Sul (UCS) , Caxias do Sul , RS , Brazil
the bone is strongest, disc height restoration, and
deformity correction and fi xation [ 5 – 7 ]. The
technique can be further improved by the use of
an endoscopic device to adequately view all the
structures [ 6 ]. This approach can avoid some of
the anterior complications of access [ 5 , 6 ].
Despite the technological advances and surgeons’ skill during the minimally invasive lateral interbody fusions, the patient can be at risk
for a number of signifi cant intraoperative and
perioperative complications. Injury to the retroperitoneal vessels is one of these potentially
catastrophic situations.
33.2 Vascular Anatomy
of the Anterior and Lateral
Region of the Lumbar Spine
The abdominal aorta artery runs the length from
the diaphragm aortic hiatus at the level of the
T12–L1 intervertebral disc to the level of L4
where it divides into the two common iliac arteries. The inferior vena cava is formed at the fi fth
lumbar vertebra by the union of the common iliac
veins and ascends to the right of the median
plane. The aorta artery is ventral to the inferior
vena cava and lumbar vertebral bodies and sits
slightly to the left, whereas the vena cava is
located slightly to the right (Fig. 33.1 ).
The abdominal aorta arises and branches
from the ventral wall (celiac, superior
© Springer International Publishing Switzerland 2017
M.Y. Wang et al. (eds.), Lateral Access Minimally Invasive Spine Surgery,
DOI 10.1007/978-3-319-28320-3_33
319
320
A. Falavigna and O.R. Neto
Fig. 33.1 Anterior view of the retroperitoneal vascular
vessels. The aorta artery runs to the left and divides at the
L4–L5 intervertebral disc into the two common iliac arteries. The inferior vena cava is formed at the fi fth lumbar
vertebra by the union of the common iliac veins and
ascends to the right of the median plane
mesenteric, and inferior mesenteric arteries)
and lateral wall (renal, the middle suprarenal,
and the testicular or ovarian arteries). The four
pairs of lumbar arteries arise dorsolaterally and
their course is dorsomedial. On the right, they
run dorsal to the inferior vena cava, dividing
between the transverse processes into the ventral and dorsal branches (Fig.
33.2 ). The dorsal
branch passes dorsally lateral to the articular
processes and supplies mainly the spinal cord
and cauda equina. The largest of these dorsal
branches denominates the radicularis magna
artery (Adamkiewicz).
Tributaries of the inferior vena cava are the
common iliac veins (L5), the lumbar veins, the
right testicular or ovarian vein (the left drains into
the left renal vein), the renal veins, the azygos
vein, the right suprarenal vein (the left also drains
into the renal vein), the inferior phrenic veins,
and the hepatic veins. The lumbar veins consist
of four or fi ve segmental pairs. They may drain
separately into the inferior vena cava or the common iliac vein.
Fig. 33.2 Right lateral view of the lumbar spine where
the lumbar arteries run dorsal to the inferior vena cava.
The inferior vena cava migrates as it descends from zone
A at L1 to zone I at L5
The distribution of abdominal large vessels
and the psoas major of each lumbar intervertebral space is inconsistent. Lumbar intervertebral
spaces were divided in six zones from the anterior to the posterior border of the vertebral body
[ 8 ]. The anterior aspect of the anterior margin of
the vertebral body was defi ned as zone A and
the posterior aspect of the posterior margin as
zone P; zones I, II, III, and IV were distributed
equally between the anterior margin and the
posterior margin from the anterior to the
posterior, respectively.
The inferior vena cava on the right side
migrates from zone A to zone I as it descends
from L1 to L5 [
9 ]. Based on the distribution of
the inferior vena cava, the right-side extreme lateral interbody fusion (XLIF) approach does not
injure the vena cava at zones II–P of intervertebral spaces L1/L2, L2/L3, L3/L4, and L4/L5
(Fig. 33.2 ) [ 10 ].
The abdominal aortas at intervertebral
spaces L1/L2, L2/L3, and L3/L4 were located
mostly to the left of zone A, 95.8 %, 85.4 %,
and 79.1 %, respectively [ 9 ]. At the L4/L5 inter-
vertebral space, about 62.6 % of the abdominal
33 Managing and Preventing Vascular Complications
321
aortas are divided into bilateral iliac arteries,
and these branches were located at zone A
(Fig. 33.3 ) [ 9 ]. Left-side XLIF approaches at
zones II–P of L1/L2–L3/L4 intervertebral
spaces and at the I–P zone of L4/L5 intervertebral space do not injure the aorta [ 9 ]. The
approach must pass through the psoas major at
zone II of L3/L4 to avoid injuring the aorta and
nerve root or else pass through the psoas major
at zones I–II of L4/L5 [ 9 ].
For convenient operation, the surgery should
be performed through the psoas major via the
location between zone II and zone III of both
lumbar intervertebral spaces of L1/L2 and L2/L3
[ 9 ]. This would not injure the vena cava and
nerve plexus. The approach must be through the
psoas major at zone II of both L3/L4 and L4/L5
to avoid injury to the vena cava and plexus
(Figs. 33.3 and 33.4 ) [ 9 ].
The position of either the inferior vein cava or
right common iliac vein with respect to the ante-
Fig. 33.4 Left lateral view of the lumbar spine where the
psoas major is located over the lumbar spine
rior intervertebral plane measured −4.3 mm at
L1–2, −1.3 mm at L2–3, even with the anterior intervertebral plane at L3–4, +2.1 mm at L4–5,
and +4.9 mm at L5–S1 (Fig. 33.1 ) [ 11 ]. When a
“typical” 20-mm operative corridor is used, the
neurovascular structures would be vulnerable to
injury at L4–5 in 21 and 44 % of patients when
using left- and right-sided approaches,
respectively (Figs. 33.2 and 33.3 ) [ 11 ].
Fig. 33.3 Left lateral view of the lumbar spine where the
aorta artery migrates is located at zone A in the intervertebral spaces L1/L2, L2/L3, and L3/L4. In the L4/L5 intervertebral space, about 62.6 % of the abdominal aortas are
divided into bilateral iliac arteries, and these branches
were located at zone A
33.3 Incidence of Vascular Complications in Lumbar Spine Surgery
Injury to the retroperitoneal vessels can occur
after posterior, anterior, or lateral approaches to
the lumbar spine.
33.3.1 Posterior Approach
Vascular lesion in the posterior lumbar interbody
fusion techniques is uncommon (0.05 %) and
usually associated with discectomy [ 12 ] or guide-
wire advancement into the vascular vessels
during the placement of percutaneous pedicle
screws [ 13 , 14 ].
322
A. Falavigna and O.R. Neto
33.3.2 Anterior Conventional Approach
There are a much greater number of vascular
injuries by anterior approach. The number ranges
from 1.3 to 15.6 % due to the presence of the
great vessels and their branches and tributaries in
the surgical fi eld or nearby where they can be
inadvertently injured either during dissection or
during retraction [ 2 ].
33.3.3 Lateral or Extreme Lateral Retroperitoneal Transpsoas Approach
In the largest XLIF series published, there was no
report of vascular complications following the
surgery in 600 patients and at 741 levels [ 15 ].
Vascular injury by XLIF procedure is only published as a case report of iatrogenic lumbar artery
pseudoaneurysm following XLIF when endovascular embolization was performed [ 16 ].
33.4 Surgical Features in Lateral Retroperitoneal Transpsoas Interbody Fusion
The use of XLIF in the lumbar spine cephalic to
L5–S1 circumvents the dissection and retraction
of the large retroperitoneal vessels that is one of
the major complications of the anterior approach
and consequently minimizes the risk of vascular
injuries [
sion that limits the visualization of the surgical
fi eld and exposes the surgeon to problems and
hazards that do not exist when doing similar
procedures in an open technique. Surgeons
depend on high-quality fl uoroscopic imaging
and must rely on intraoperative fl uoroscopic
images and electromyography monitoring during most of the procedure. Specifi c risks include
injury to the exiting nerve root and laceration of
the retroperitoneal vessels during the deployment of the surgical retractors and the discectomy procedure [ 18 ].
15 , 17 , 18 ].
The XLIF technique uses a small 3-cm inci-
The neurovascular structures would be vulnerable to injury at L4–5 in lateral transpsoas
approach with a higher incidence using rightsided (44 %) rather than left-sided (21 %)
approaches [ 11 ].
The surgeons must bear in mind that it is
usually during L4–L5 XLIF that a high percentage of patients require neurovascular
retraction, especially on the right side. The
neurovascular anatomy must be well studied
during preoperative planning in order to detect
the patients that may not be ideal candidates
for this approach [ 11 ]. Besides neurovascular
retraction, the risk of vascular lesion is signifi cantly increased at the L4–L5 level because the
more anterior position of the nerve root forces
the discectomy window more anteriorly, which
in turn increases the risk of injury to the ipsilateral and contralateral vessels and the relatively posterior location of the retroperitoneal
vascular structures [ 18 ].
The risks are further increased with rotational
deformity of the spine [ 18 ]. In the case of scolio-
sis, the vessels on the concave side of the curvature were positioned relatively posterior to their
position in the normally aligned spines [ 18 ]. The
overlap of the right vessels over the vertebral
body reached 43.9 % in the levoscoliotic spines,
compared with 12.2 % in the normal group. The
left vessels’ overlap in the dextroscoliotic spines
reached 19.8 %, compared with 1.2 % in the normal group ( P < 0.05). As a result of the greater
degree of overlap between the neurovascular
structures and the vertebral body found in the
scoliosis subgroup, the surgical safe zone
decreased to 40 % in the levoscoliotic spines and
61 % in the dextroscoliotic spines, compared with
70 % in the nonscoliotic group. The altered location of the neurovascular structures depended
mostly on the degree of rotatory deformity, measuring 12° in the levoscoliotic and 11° in the dextroscoliotic spines. Focal coronal deformity or
lateral listhesis did not seem to affect the position
of these structures [
Meticulous care and consideration of these
anatomic characteristics are required for safe
application of this minimally invasive technique
[ 11 , 15 , 17 , 18 ].
18 ].
33 Managing and Preventing Vascular Complications
323
33.5 Preventive Measures of Vascular Complications in Anterior Lumbar Spine Surgery
The popularity and the increasing numbers of
XLIF procedures highlight a better understanding of the expected complications, the predictive
factors for the patient, and the surgical technique
and preventive measures [ 5 , 19 ]. The measures
adopted to prevent vascular injury start with good
preoperative planning, expert skills during surgery, and close monitoring in the postoperative
period (Table 33.1 ).
33.5.1 Preoperative Period
Accurate preoperative planning means: (1) precise knowledge of the location of the lumbar
nerve roots, abdominal wall nerves, and nerves
on the surface of the psoas muscle; (2) identifi cation of the vascular position and its relation to the
pathology and the surgical corridor; (3) high
Table 33.1 Preventive measures for vascular complications in anterior or lateral lumbar spine surgery during the
preoperative, operative, and postoperative period
Patient care Preventive measures
Preoperative
period
Operative
period
Postoperative
period
Good preoperative planning
Identifi cation of vascular position and
its relation to the pathology and the
surgical corridor
Knowledge of anatomy of the
deformity
Knowledge of the patient-related
variables
Mechanical and pharmacological
prevention of venous thrombi in the
lower limbs
Careful positioning of the patient’s
legs
Three-dimensional anatomic
knowledge of the surgical area
Gentle surgical manipulation
Adherence to intraoperative EMG
Avoid endplate violation during
discectomy and implant insertion
Thromboembolic prophylaxis
Early patient mobilization
point of the iliac crest and its correlation with the
lumbar spine; (4) anatomy of the deformity with
information about the coronal and sagittal angle,
vertebra rotation, asymmetry of the intervertebral
disc, lateral listhesis, and presence of the osteophytes; and (5) knowledge of the patient-related
variables, such as age, BMI, bone densitometry,
and comorbidities [ 20 ].
Preoperative planning in XLIF surgery after
the study of the neurovascular anatomy will
detect a signifi cant percentage of patients who
may not be ideal XLIF candidates. The radiological preoperative evaluation of the spine and vascular anatomy dictate the decision to adopt a
right or left lateral decubitus approach.
33.5.2 Operative Period
The operative steps to prevent vascular
complications are:
1. Prevention of a venous thrombus in the lower
limbs
2. Careful positioning of the patient’s legs
3. Three-dimensional anatomic knowledge of
the surgical area
4. Gentle surgical manipulation
5. Adherence to intraoperative EMG for real-
time identifi cation of the lumbar plexus within
the psoas muscle
6. Avoiding endplate violation during discectomy
and implant insertion by the use of fl uoroscopic
visualization during the procedure [
Proper patient positioning is essential for a
successful procedure. The patient must be
secured to the operating table in a manner that
prevents movement during the surgical procedure,
so that the orientation remains the same for the
surgeon. Once the patient has been securely positioned, image intensifi er-based views of the spine
are obtained. It is important to obtain images in
true lateral and AP projections.
To prevent or minimize vascular complications
during XLIF, the surgeons must have an anatomic
understanding of the relationship between the
ventral nerve roots, the retroperitoneal vessels,
21 ]