Laparoscopic discectomy with anterior interbody fusion of L5-S1

Background: A laparoscopic approach to the spine for the performance of a minimally invasive discectomy was first described in 1991. Since that time, a number of approaches to laparoscopic discectomy have appeared in the literature. Although these reports demonstrate the ability to approach the spine through a laparoscopic technique, they do not address the issues of loss of disc space, lumbar instability, and the need for interbody fusion. Methods: Described is a technique of laparoscopic discectomy with interbody fusion that has been performed successfully in 75 patients. Although a carbon fiber implant was utilized to aid in the fusion process, the technique can equally be performed using donor bone as the interbody support. In the 75 patients attempted, 73 procedures were successfully completed via the laparoscopic approach. One patient was converted to an open anterior approach due to extensive pelvic adhesions from prior surgery. A second patients procedure was aborted after the diagnostic laparoscopy demonstrated dense presacral scarring from a previous gynecological procedure. Results: There were no major complications in the series. Two patients with high riding bladders sustained bladder lacerations that were recognized and repaired with simple suture closure. There were no bowel injuries, and more importantly, no major vessel injury. The patients were discharged from the hospital on an average within 36 hours, with a return to work averaging between 2–4 weeks depending on the patients type of work. Using a modified pain score for evaluation, post operative pain was reduced by 75%. Conclusions: From this study, it is concluded that laparoscopic discectomy with interbody fusion is not only feasible, but appears to give good results with follow up extending out beyond two years. Issues regarding the use of carbon fiber cages vs. bone and indications of the procedure are independent of the laparoscopic approach and are addressed extensively in the orthopedic literature. It can be concluded that when there is surgical indication for L5-S1 discectomy, that a laparoscopic approach with interbody fusion may become the procedure of choice. Received: 14 May 1996/Accepted: 15 June 1996     

Computed tomography in the diagnosis of a herniated disk at the L5-S1 level

Six patients with a normal myelogram were found to have evidence of a herniated nucleus pulposus (HNP) at the L5-S1 level on computed tomography (CT) scan. In all six patients, the presence of the herniated disk was confirmed at surgery. Five of the six herniations were lateral. The authors found no patients with an abnormal myelogram and a normal CT at the L5-S1 level in a technically good study. The sensitivity of the CT in diagnosing an HNP at the L5-S1 interspace is greater than with myelography if images in the exact plane of the disk can be obtained.     

Comparison between the antero-posterior and anterior approaches for treating L5-S1 vertebral tuberculosis

Purpose  

Both the antero-posterior and anterior approaches have been used for treating L5-S1 vertebral tuberculosis. However, no studies have compared the efficacy of the two methods in treating the disease.     

Video-assisted ALIF with cage and anterior plate fixation for L5-S1 spondylolisthesis

INTRODUCTION: Spondylolysis and spondylolisthesis grade 0, 1, and 2 are mainly asymptomatic but with aging process and different factors some back pain can occur and lead to chronic low back pain. The conservative treatment with physiotherapy and steroid injection is the gold standard but in some cases is not efficient enough and a surgical treatment is proposed. OBJECTIVES: The goal of this study is to propose a new technique to treat grade 0, 1, and 2 spondylolisthesis with an anterior video-assisted fusion and stabilization. METHODS: Twenty patients with chronic low back pain since more than 2 years and resistant to conservative therapy were included in this protocol. Clinical signs and radicular pain were noted. They were evaluated preoperatively and postoperatively until the last follow up using Oswestry score and visual analog score (VAS) for leg and back pain. X-rays showed grade 0 (8 cases), 1 (10 cases), and 2 (2 cases) spondylolisthesis according to Meyerding classification with disc collapse (bulging disc). MRI showed in all cases a disc degeneration with at least black disc and/or endplates changes with Modic I or II. All patients were operated using an anterior video-assisted retroperitoneal approach, with discectomy and fusion using an anterior impacted cage filled with autologous cancellous bone from the iliac crest and an anterior fixation with a triangular plate (Pyramid, Medtronic, Memphis). The follow up at 3, 6, 12, and 24 months was done with clinical and radiologic evaluation. In case of problem a computed tomography scan was performed. RESULTS: There were 11 women and 9 men, with and average age of 39 years old and a BMI of 25.6. All spondylolistheses occurred at level L5. The average slippage was 19%. All L5S1 discs were black, 8 had a Modic I changes in the endplates and 2 had Modic II. The shape of L5 vertebra was abnormal (trapezoidal) in 7 cases. All anterior approaches were performed without vascular, urologic, or digestive complication. Blood loss was inferior to 100 mL. All patients had a soft brace for 8 weeks postoperatively. There was no retrograde ejaculation for the 9 men and no sexual dysfunction reported by the women. One patient had no pain relief and was reoperated for posterior pedicular screw fixation. It was obvious that there was a pseudarthrosis even after the posterior fixation and an anterior transperitoneal revision was performed with the removal of the interbody device and iliac crest bone graft packing alone. A propioni bacterium acnes germ was found responsible for the anterior nonunion. This revision surgery with antibiotics treatment was successful. One of the patients with grade 2 had an additional posterior screw fixation with a minimally invasive pedicle screw system (Sextant, Medtronic, Memphis). Nineteen patients had a good fusion at 2 years follow-up (95%), mean Oswestry score improved from 74% preoperative to 21% postoperative at the last follow-up. Visual analog score (VAS) for back pain improved from 6.5 to 2.7 and VAS for leg pain improved from 6.2 to 3.4. Satisfaction rate was 90%. All active patients except two, were back to work at an average of 5.5 months (6 wk to 1 y). The 2 patients still not working were the nonunion and a work compensation. CONCLUSIONS: The results of this technique compare favorably with posterior stabilization and fusion (posterior lumbar interbody fusion and postero-lateral fusion) reported in the literature. Unlike posterior lumbar interbody fusion, however, it seems that the complication rate due to the approach is much lower, the fusion rate is similar. Grade 2 SPL is the limitation of the technique. The main advantage of the technique is to avoid posterior muscle damage and a quick recovery with no blood loss. Preservation of adjacent level disease can be assessed only after long-term follow-up.     

Acute traumatic L5-S1 spondylolisthesis

Acute traumatic L5-S1 spondylolisthesis is a rare condition, almost exclusively the result of major trauma, frequently associated with L5 transverse process fracture and neurologic deficit. In recent years, open reduction and internal fixation with posterior stabilization has been the method of treatment most frequently reported. In the current case, the lesion was found in a victim of an automobile accident. Signs of a right L5 root deficit but no sphincter dysfunction were present. A computed tomography scan revealed several fractures in the posterior parts of L5 and anterior displacement of L5 on S1. A magnetic resonance imaging (MRI) scan verified that the lesion was indeed acute by showing the ruptured L5 disc and posterior ligaments, thereby demonstrating the importance of MRI in the planning of the treatment of these lesions. This case was successfully treated with an acute circumferential instrumented L4-S1 spondylodesis.     

Traumatic spondylolisthesis of L5-S1

Pure traumatic bilateral lumbosacral dislocation is a rare injury with just eight cases reported in the literature. This condition occurred also in 36-year-old man, who was struck into the lower back by a falling tree, during a woodcutting, at the moment when he was kneeling and his spine was flexed. Neurological examination showed no signs of spinal nerves injury. X-ray examination of the lumbosacral spine revealed the presence of a 40% anterior dislocation of L5 over S1 with locked facets and multiple fractures of transverse processes. Computer tomography confirmed these findings and also revealed massive medial L5-S1 disc herniation. Surgery performed 9 days after the injury consisted of L5 laminectomy, L5-S1 discectomy and segmental reduction and stabilization with transpedicular screws. Posterior lumbar interbody fusion was carried out using titanium PLIF-blocks. The patient healed without complications. At a 24-month follow-up he was without any subjective complaints, neurologically asymptomatic and without restriction of mobility in the lumbosacral spine. He was able to resume his previous work. This rare case is discussed in a view of the relevant literature, biomechanics of trauma and the appropriate therapy with an emphasis on open reduction and internal fixation techniques.     

L5-S1 Laparoscopic Anterior Interbody Fusion

Objective:

We evaluated our experience with laparoscopic L5-S1 anterior lumbar interbody fusion (ALIF).

Methods:

This represents a retrospective analysis of consecutive patients who underwent L5-S1 laparoscopic ALIF between February 1998 and August 2003.

Results:

Twenty-eight patients underwent L5-S1 LAIF (15 males and 13 females). The mean age was 43 years (range, 26 to 67). Mean operative time was 225 minutes (range, 137 to 309 minutes). No conversions to an open procedure were necessary. Twenty-four (85.7%) patients underwent successful bilateral cage placement. Four patients (14.3%) in whom only a single cage could be placed underwent supplementary posterior pedicle screw placement. Mean length of stay (LOS) was 4.1 days (range, 2 to 15). Two patients underwent reoperation subacutely secondary to symptomatic lateral displacement of the cage. One patient developed radiculopathy 6 months postoperatively and required reoperation. One patient developed a small bowel obstruction secondary to adhesions to the cage requiring laparoscopic reoperation. Fusion was achieved in all patients. Visual analogue scale scores for back pain were significantly improved from 8.6±0.8 to 2.8±0.8 (P<0.0001) at 1 year.

Conclusion:

L5-S1 LAIF is feasible and safe with all the advantages of minimally invasive surgery. Fusion rates and pain improvement were comparable to those with an open repair.     

Laparoscopic spinal fusion of L4-L5 and L5-S1

Background: Patients with degenerative disc disease were treated by laparoscopic spondylodesis. Clinical outcome and quality of life were then analyzed in a retrospective study. Methods: Thirty patients with a mean age of 43 years (range, 26-63) who suffered from instability of levels L4-L5 (n = 23), L5-S1 (n = 3), or both (n = 2) underwent surgery. Spondylodesis was achieved with two BAK cylinders. After ?6 months, all patients completed a questionnaire designed to assess satisfaction with the operative outcome. Results: After a median follow-up of 2.3 years (range, 0.9-3.5), 23 patients were free of pain or greatly improved. Complications included bleeding (n = 2), cage displacement (n = 1), retrograde ejaculation (n = 3), and postoperative ileus (n = 1). Good improvement was reported in daily activities and quality of life. Conclusion: Laparoscopic spondylodesis has a good clinical outcome with a low rate of morbidity. Notable improvements can be achieved in terms of daily activities and quality of life; however, these improvements are moderate in degree, and patient activity remains somewhat limited.     

The anatomical feasibility of anterior intra- and extra-bifurcation approaches to L5-S1: an anatomic study based on lumbar MRI

BACKGROUND CONTEXTThe anterior approach at L5-S1 has many advantages, however, vascular complications are challenging for spinal surgeons who may not be familiar with the variability of vascular anatomy. There are three different anterior approaches (intra-bifurcation approach and extra-bifurcation: left-, and right-sided prepsoas approaches) described in previous studies to respond to the variability of anterior vascular anatomy for reduction in vascular injury, while no guidance for the choice of approach preoperatively.PURPOSETo analyze the anatomical feasibility of three anterior approaches to access the L5-S1 disc space according to a practical framework.STUDY DESIGNRetrospective study.PATIENT SAMPLELumbar magnetic resonance imaging (MRI) from patients who visited our outpatient clinic were reviewed, with 150 cases meeting the inclusion criteria.OUTCOME MEASURESThe following radiographic parameters were measured on axial T2-weighted MRI at the lower endplate of L5 and the upper endplate of S1: width of the vascular corridor, position of the left and right common iliac vein (CIV), and presence of perivascular adipose tissue (PAT). Moreover, we designed a safe line to evaluate the feasibility of left- and right-sided prepsoas approaches. Cases of lumbosacral transitional vertebrae were identified.METHODSThe feasibility of the intra-bifurcation approach was determined by the width of the vascular corridor, presence of PAT, and the position of the CIV. The feasibility of the prepsoas approach was determined by the relative position of the CIV to the safe line, presence of PAT, and the intersection point of the CIV and vertebral body.RESULTSSixty-eight percent, 64.7%, and 75.3% cases allowed the intra-bifurcation, left-, and right-sided prepsoas approach to L5-S1, respectively. The cases in this study had at least one of three anterior approaches to access L5-S1 disc space, and 74% of cases had more than one anatomical feasibility of anterior approach. The right-sided prepsoas approach was feasible in the majority of cases because of the vertical course of the right CIV with a significantly higher proportion of presence of PAT. Patients with lumbosacral transitional vertebrae (24 cases) may prefer the prepsoas approaches, and only six cases (25.0%) were determined to be feasible for the intra-bifurcation approach.CONCLUSIONSOur study proposes a practical framework to determine whether the three different anterior approaches are feasible access at L5-S1. According to the framework, all cases had the anatomical feasibility of using an anterior approach to access L5-S1, and three-fourths of cases had a replaceable anterior approach when encountering intraoperative difficulties.     

3D-location of the L5-S1 fulcrum in relation to the hip

The purpose of the present study was to measure the three-dimensional distance between the hips and L5-S1 joint in vivo so that this data could then be used in computer programs predicting the load at the lumbosacral joint from posture and anthropometric data. Twenty-one subjects were investigated with computed tomography; consecutive transverse slices were taken from the low-back to proximal thigh, and three-dimensional coordinates were recorded. The distance between the hips and the L5-S1 joint was 122 mm, corresponding to 6.9% and 7.5% of body height for men and women, respectively (P less than 0.05).     

Postoperative spinal alignment comparison of lateral versus supine patient position L5-S1 anterior lumbar interbody fusion

European Spine Journal - Over the past decade, alternative patient positions for the treatment of the anterior lumbar spine have been explored in an effort to maximize the benefits of direct...     

Paradoxical motion in L5-S1 adult spondylolytic spondylolisthesis

Introduction  

In patients with spondylolisthesis, it is assumed that flexion accentuates anterior displacement, whereas extension causes some reduction. Paradoxical movement—where flexion causes reduction of spondylolisthesis and extension increases the anterior translation, is rarely described. In this study, we investigate the prevalence of paradoxical motion in patients with L5-S1 spondylolytic spondylolisthesis and why this abnormal motion occurs.     

Limited (L4-S1, L5-S1) Selective Dorsal Rhizotomy for Reducing Spasticity in Cerebral Palsy

Summary  Selective posterior rhizotomy is effective for relieving spasticity associated with cerebral palsy. In current techniques dorsal roots from L1/L2 to S1/S2 are selectively divided. With transoperative electromyography (EMG) significant sensory loss has been prevented, but postoperative hypotonia following excessive reduction of the fusimotor drive is still of concern for surgeons and therapists. To decrease the volume of deafferentiated rootlets we proposed a limited selective posterior rhizotomy (LPSR) that limits the extent of the surgery to three (L4-S1) or two (L5-S1) dorsal roots. We present the results of two group of spastic children; group 1 (n=59, 32 quadriplegic and 27 diplegic) who had a L4-S1 LPSR. and group 2 (n=12) in whom L5 and S1 were selectively rhizotomized. Posture, passive movilization, range of joint movement, and muscle tone in hip flexors, adductors, leg flexors and plantar flexors were graded according to the method proposed by Sindou and Jeanmonod. In all groups there was a significant reduction of the mentioned parameters (Friedman test p<0.001) at 6, 12 and 18 months after surgery. The preoperative and postoperative ability to ambulate was classified into five grades. In all groups there was a significant (χ² between p<0.01 and p<0.001) improvement in the quality of their gait. A third of the patients achieved some form of independent ambulation. Our results suggest that extensive selective deafferentation of the lower limbs is not an absolute requisite for reducing muscle tone or achieving functional improvement in spastic children.     

国人下腰椎前方血管解剖结构特点和入路分型

目的研究国人下腰椎前方血管与椎间隙之间的解剖特点,并进行解剖结构分型,为下腰椎前路椎间融合手术入路,尤其是腹腔镜下手术入路的选择提供解剖学依据。方法随机抽取94例国人腰椎MRI片,观察腰3-4、腰4-5,腰5-骶1椎间隙横断面前方的大血管解剖结构,判断腹主动脉的分叉位置和左髂总静脉与下腔静脉汇合位置,并进行解剖结构分型。结果根据腹主动脉分叉、左髂总静脉与下腔静脉汇合点与腰。椎间隙的上边缘之间的关系,确定4种类型。21例(22.3％)被归为A类(低分叉／低汇合),34例(36．2％)被归为B类(高分叉／高汇合),38例(40．4％)被归为C类(高分叉／低汇合),1例(1．1％)被归为D类(低分叉／高汇合)。在腰5-骶1间隙腹主动脉均已分叉,左髂总静脉均未汇合。男女之间无显著性差异。结论下腰椎前方血管解剖位置具有多变性,以腰4-5椎间隙为著,使腹腔镜下手术入路变的复杂。术前常规腰椎。MRI图像能用来进行血管解剖位置的分类,并设计最佳的手术入路。