Nowadays many new minimally invasive techniques are experienced to perform lower lumbar interbody fusion in attempt to decrease the complications related to open anterior approach. AxiaLIF (axial lumbar interbody fusion) system is a percutaneous transacral approach that exploits the virtual presacral retroperitoneal space to perform annulus-sparing discectomy and interbody instrumented fusion of lower lumbar disc spaces. Additioning posterior percutaneous instrumentation, a robust axial construct is placed which restores disc height, sagittal balance and lordosis with minimal muscle dissection, blood loss and postoperative pain. Via fluoroscopically-guided approach, AxiaLIF procedure creates a presacral retroperitoneal corridor in the midline through a paracoccigeal skin incision of 2-3 cm. This space is void of neuro-vascular major elements. A safe working cannula is put in and docked in the S1-S1 entry level and a transacral channel is realized gaining the central space of the disc. A 360° annulus-sparing radial discectomy is performed with special cutters even in case of collapsed disc space and the bone graft is inserted. The following screwing of AxiaLIF rod restores disc height via distraction if necessary, decompresses the neural foramen indirectly and undertakes instantaneous rigid fixation of adjacent vertebral bodies. Using the same incision point and trajectory through the presacral space as AxiaLIF, it is possible to realized a similar procedure L4-S1 vertebral fusions called AxiaLIF 2L. Between february 2009 and may 2010 25 patients (16F:9M) affected by degenerative disc disease (17) and grade 1 or 2 spondylolisthesis (8) were included in this study. Evaluated outcomes were the amount of bleeding, the presence of presacral hematoma, the functional recovery time, the surgery time rate, the x-ray time rate, the complication rate (infection, pelvic visceral injury, postoperative pain). 21 of 25 patients underwent AxiaLIF L5-S1 procedures, 4 of these with a stand alone implant and 17 followed by posterior instrumentation. In the remaining 4 patients, a AxiaLIF 2L L4-S1 procedures is performed. 4 of 25 patients had a perioperative suction drenage. Mean operative time for L5-S1 AxiaLIF procedure was 49 minutes. A 2nd p.o.d. CT pelvic scan of undrained and drained groups showed a mean presacral hematoma of 45 cc and 17 cc respectively reduced one month later to a mean value of 19 cc and 3 cc. Hemoglobin rate mainly reduced of 1,7 g/dL between pre and postoperative time. At one month all patients improved their quality of life significantly but one had a gluteal pain. No patient had perioperative infections or pelvic visceral injuries or required blood transfusions. This study seems to assess that AxiaLIF procedure is a minimally invasive lower spine techique actually. The presacral hematoma presence seems to have no side effect and it may be prevented by perioperative drainage. More large studies are needed to confirm our results.
