Abstract
Introduction There is presently great interest throughout the world for total disc arthroplasty (TDA). This paper aims to present techniques that make it safer, easier and faster for the surgeon to perform the anterior, retroperitoneal approach to the lumbar spine necessary for the implantation of these artificial discs (Brau SA, et al ; The Spine Journal, 2004).
Methods The author has performed over 200 approaches for TDA since May of 2001. In addition he has performed approaches for over 2000 arthrodesis cases since August of 1997. Analysis of these cases has revealed techniques that can make the approach faster and easier while helping to prevent complications.
Results Prevention of complications starts with the pre-operative evaluation of the patient. Individuals with a BMI of 40 or over and patients with vascular calcifications have potential for increased vascular complications. Pedal pulses must be evaluated in every patient prior to surgery. The lateral X-ray of the lumbar spine must be seen to evaluate for the presence of osteophytes and calcified vessels, both of which increase the morbidity of the operation. A pulse oxymeter should be placed on the left great toe to evaluate the status of the left iliac artery during the procedure. Disc level localization by fluoroscopy is necessary for the placement of the recommended transverse incision in optimal location. Circumferential left rectus mobilization for single level cases will help keep the incision small. The ureter and the superior hypogastric plexus should be mobilized with the peritoneum to keep them from injury. Distal mobilization of the left iliac artery will help reduce the incidence of thrombosis of this vessel and ligation of the ileo-lumbar vein will help reduce the chances of left iliac vein laceration when exposing L4-5. Reverse lip retractors blades help to keep the incision small and to protect the vessels from injury.
Discussion These techniques have helped reduce the incidence of left iliac artery thrombosis to 0.45% (6 in 1310) and of major vein laceration to 1.4% (19 in 1310) in a series of patients published in 2004. The incidence of ureteral injury and of retrograde ejaculation in these same patients was reduced to 0. The techniques should, therefore, be helpful to the access surgeon in performing the approach safely and more expeditiously.
The abstracts were prepared by Professor Bruce McPhee. Correspondence should be addressed to him at Orthopaedics Division, The University of Queensland, Clinical Sciences Building, Royal Brisbane & Women’s Hospital, Herston, Qld, Australia
