Introduction The purpose of this study is to determine the incidence of revisions following a large series of lumbar arthroplasties and to develop approach strategies for these revisions.

Methods 393 patients had lumbar arthroplasty between May of 2001 and December of 2005. Follow-up ranges from 4 years 7 months to 3 months. So far there is 100% follow-up on these patients. Only those returning for anterior revision of the device have been included in this study.

Results Overall revision rate was about 2% (8 of 393). 307 patients had a ProDisc L and 2 were revised (0.6%). One was removed and one was repositioned and remains in place 18 months post-op. 66 patients had a Charité and 5 (7.5%) had to be removed followed by antero-posterior fusion. 20 patients had a Flexicore and 1 was removed followed by fusion (5%). 5 of the revisions happened within three weeks of implantation. 1 ProDisc L was removed 8 months post-op due to anterior extrusion. 1 Charité was removed 15 months later after a posterior fusion and continued pain and 1 was removed 8 months later due to subsidence. 6 revisions were at L5–S1 and 2 were at L4–5. The 8 revisions were done successfully and without complications. All the ProDisc L and Flexicore devices were implanted as part of investigational studies. All the Charité devices were implanted after the device was approved for use in the USA in October of 2004.

Discussion It appears that revision arthroplasty is inevitable although there appears to be a difference in the early revision rate depending on the device used. Revisions at L4–5 have proved to be extremely challenging and require significant experience on the part of the surgeon. Pre and intra-operative strategies and techniques used in these cases include: pre-op imaging studies such as venograms, MRV’s and color coded radial CT scans, placement of ureteral catheters, use of pulse oxymeter in the left great toe, balloon catheters to control bleeding and use of the cell saver.

As a rule, after 10 to14 days a revision approach via the same incision should be avoided. At L5–S1 it is best to use the opposite side retroperitoneal approach. L4–5 should be approached either transperitoneally or via a more lateral retroperitoneal incision. Returns to L3–4 and L2–3 are best via a more lateral approach as well. Right-sided approaches should only be used for L5–S1. For higher levels, potential injuries to the inferior vena cava make the risk prohibitive.

Introduction Based on 27 years of peripheral vascular surgery practice and 21 years of experience in performing anterior lumbar spine approaches the author will make recommendations for management of the more common complications of the approach to the lumbar spine.

Methods A database of 2020 cases performed since August of 1997 has been evaluated to determine the best way to manage the complications of the approach encountered in that time period.

Results 6 patients had left iliac artery thrombosis (0.29%) and 24 had major vein lacerations (1.1%). Two patients developed compartment syndrome and two other patients required arterial reconstruction. One of the patients had ureteral injury. None of the patients had retrograde ejaculation, lymphoedema, bowel injury or neurological injury. Left iliac artery thrombosis is best managed by immediate thrombectomy using balloon catheters, either via the main incision of via a left femoral incision. The diagnosis is clinical and the patient should not be taken to the radiology department for diagnostic angiography. Avoidance of delay is important in preventing compartment syndrome. If ischemia is present for 4 hours or more a prophylactic fasciotomy may be indicated. For patients with intimal disruption or atherosclerosis, in whom thrombectomy fails, arterial reconstruction or stenting may be necessary and is best left to a vascular surgeon. Venous lacerations can be repaired using 5-0 monofilament sutures. Lacerations of 5mm or less that are not easily accessible can be treated with hemostatic agents and pressure. For major disruptions of the iliac veins or inferior vena cava ligation of these vessels is an acceptable option. Proximal and distal control of vessels during exposure is not necessary and may actually lead to a higher incidence of arterial thrombosis. Control of bleeding can usually be obtained by pressure with sponge sticks or balloon catheters. The sympathetic fibres run with the peritoneum and retrograde ejaculation can be avoided by carefully elevating the peritoneum away from the promontory with blunt dissection while exposing L5-S1. The ureter similarly runs with the peritoneum and should be lifted away with it to prevent devascularization. Lymphedema is due to the disruption of the lymphatics while mobilising the iliac vessels. It is very rare and unavoidable. Injury to the genito-femoral nerve is avoided by identifying it over the psoas muscle and preserving it from injury. Bowel injury is prevented by staying retroperitoneal.

Discussion Anterior exposure to the lumbar spine carries with it a low complication rate, but these complications can have significant negative results. Prompt recognition and management of these complications will result in lower overall morbidity.

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.