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Purpose: Screwed anterior lumbar interbody fusion (SALIF) alleviates the need for supplemental posterior fixation leading to reduction of perioperative morbidity. Specifically, elderly and multimorbid patients would benefit from shorter operative time and faster recovery but tend to have low bone mineral density (BMD). The current study aimed to compare loosening, defined as increase of ROM and NZ, of SALIF versus transforaminal lumbar interbody fusion (TLIF) under cyclic loading in cadaveric spines with reduced BMD. Methods: Twelve human spines (L4–S2; 6 male 6 female donors; age 70.6 ± 19.6; trabecular BMD of L5 84.2 ± 24.4 mgHA/cm3, range 51–119 mgHA/cm3) were assigned to two groups. SALIF or TLIF were instrumented at L5/S1. Range of motion (ROM) and neutral zone (NZ) were assessed before and after axial cyclic loading (0–1150 N, 2000 cycles, 0.5 Hz) in flexion–extension (Flex–Ext), lateral bending, (LB), axial rotation (AR). Results: ROM of the SALIF specimens increased significantly in all loading directions (p ≤ 0.041), except for left AR (p = 0.053), whereas for TLIF it increased significantly in left LB (p = 0.033) and Flex (p = 0.015). NZ of SALIF showed increase in Flex–Ext and LB, whereas NZ of TLIF did not increase significantly in any motion direction. Conclusions: Axial compression loading caused loosening of SALIF in Flex–Ext and LB, but not TLIF at L5/S1 in low BMD specimens. Nevertheless, Post-cyclic ROM and NZ of SALIF is comparable to TLIF. This suggests that, neither construct is optimal for the use in patients with reduced BMD. [ABSTRACT FROM AUTHOR]

Purpose: The optimal surgical management of low- and high-grade isthmic spondylolisthesis (LGS and HGS -IS) is debated as well as whether reduction is needed especially for high-grade spondylolisthesis. Both anterior and posterior techniques can be associated with mechanical disadvantages as hardware failure with loss of reduction and L5 injury. We purpose a novel endoscopic-assisted technique (Sled technique, ST) to achieve a complete reduction in two surgical steps: first anteriorly through a retroperitoneal approach to obtain the greatest part of correction and then posteriorly to complete reduction in the same operation. Methods: ST efficacy and complications rate were evaluated through a retrospective functional and radiological analysis. Results: Thirty-one patients, 12 male (38.7%) and 19 female (61.3%), average age: 45.4 years with single level IS underwent olisthesis reduction by ST. Twenty-three IS involved L5 (74.2%), 7 L4 (22.5%) and 1 L3 (3.3%). No intraoperative complications were recorded. One patient required repositioning of a pedicle screw. A significant improvement of functional and radiological parameters (L4-S1 and L5-S1 lordosis) outcomes was recorded (p < 0.001). Conclusion: ST provides a complete reduction in the slippage in LGS and HGS. The huge anterior release as well as the partial reduction in the slippage by the endoscopic-assisted anterior procedure, because of the cage is acting as a "guide rail", facilitate the final posterior reduction, always complete in our series, minimizing mechanical stresses and neurological risks. ClinicalTrials.gov Identifier: NCT03644407. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the clinical and radiographical outcomes between OLIF and ALIF in treating lumbar degenerative diseases. Methods: We searched PubMed, Embase, Web of Science, and Cochrane Library for relevant studies. Changes in disc height (DH), segmental lordosis angle (SLA), lumbar lordosis (LL), visual analogue scale (VAS) score, and Oswestry disability index (ODI) between baseline and final follow-up, along with other important surgical outcomes, were assessed and analysed. Data on the global fusion rate and main complications were collected and compared. Results: Approximately, 2041 patients from 36 studies were included, consisting of 1057 patients who underwent OLIF and 984 patients who underwent ALIF. The results reveal no significant difference in DH, SLA, VAS score, and ODI between the two groups (all P > 0.05). The operation time, estimated blood loss, and length of hospital stay were also comparable between the two groups. Over 90% of the fusion rate was achieved in both groups. The OLIF group showed a higher complication rate than the ALIF group (OLIF 18.83% vs ALIF 7.32%). Conclusions: OLIF leads to a higher complication rate, with the most notable complication being cage subsidence. Both OLIF and ALIF are effective treatments for degenerative lumbar diseases and have similar therapeutic effects. ALIF was expected to be more expensive for patients because of the necessity of involving vascular surgeons. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate reasons and their frequency for why spine surgeons subspecializing in total disc replacement (TDR) performed lumbar fusion rather than TDR.Methods: The study was based on a consecutive series of 515 patients undergoing lumbar TDR or fusion during a 5-year period by three surgeons specializing in TDR. For each fusion patient, the reason for not performing TDR was recorded.Results: TDR was performed in 65.4% (n = 337) of patients and the remaining 34.6% (n = 178) underwent anterior lumbar interbody fusion (ALIF ± posterior instrumentation). Of the 178 fusion patients, the most common reason for fusion was combined factors related to severe degenerative changes (n = 59, 11.5% of the study population). The second most common reason was > Grade 1 spondylolisthesis (n = 32, 6.2%), followed by insurance non-coverage (n = 24, 4.7%), and osteopenia/osteoporosis (n = 13, 2.5%). Fusion patients were significantly older than TDR patients (52.5 vs. 41.6 years; p < 0.01). There was no significant difference with respect to gender (41.2% female vs. 43.8% female, p > 0.05) or the percentage of patients with single-level surgery (61.2% vs. 56.7%, p > 0.05).Conclusion: The most common reason for not performing lumbar TDR was related to anatomic factors that may compromise stability of the operated segment and/or TDR functionality. The older age of fusion patients may be related to these factors. This study found that many patients are appropriate candidates for lumbar TDR. However, even among TDR subspecialists, fusion is preferred when there are factors that cannot be addressed with TDR and/or may compromise implant functionality. [ABSTRACT FROM AUTHOR]

Objective: Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) are among the most popular surgical options for lumbar interbody fusion. If non-union occurs with consequent pain and reduced quality of life, revision surgery should correct any previous technical errors, avoiding further complications. The aim of this study was to analyze technical advantages, radiological and clinical outcomes of anterior approaches (ALIF) in case of failed PLIF or TLIF. Methods: Retrospective analysis of consecutive patients with persistent low back pain after failed PLIF/TLIF where salvage ALIF through an anterior retroperitoneal miniopen video-assisted technique was performed. Surgical, clinical and radiological data were analysed. Uni and multivariate statistical analysis were applied. Results: Thirty-six patients (average age: 47.1 years) were included. Mean follow-up was 34.4 months. In 30 patients (83.3%) a posterior surgical step was necessary. Non-union (86.1%), cage migration (5.5%), infection (8.3%) were the causes of revision surgery. In 22 patients (61.1%) the involved level was L5-S1, in 12 patients (33.4%) L4–L5, in 1 patient (2.7%) L3–L4. One patient (2.7%) had two levels (L4–L5 and L5–S1) involved. No major intraoperative complications were recorded. Significant correlation between clinical and radiological outcomes (L4–S1 and L5–S1 lordosis improvement) were observed (postoperative VAS and L5–S1, p = 0.038). Conclusions: Salvage ALIF is a safe option that can significantly ameliorate residual pain achieving primary interbody stability with an ideal segmental lordosis according to pelvic parameters. The advantages of a naive anterior approach fulfils the main objectives of a revision surgery in order to significantly increase the chances of definitive fusion. [ABSTRACT FROM AUTHOR]

Purpose: We aim at analysing the impact of anterior lumbar interbody fusion (ALIF) in restoring the main spinopelvic parameters, along with its potentials and limitations in correcting sagittal imbalance. Materials and methods: The 2009 PRISMA flow chart was used to systematically review the literature; 27 papers were eventually selected. The following spinopelvic parameters were observed: pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), segmental lumbar lordosis (LLseg) and sagittal vertical axis (SVA). Papers reporting on hyperlordotic cages (HLC) were analysed separately. The indirect decompression potential of ALIF was also assessed. The clinical outcome was obtained by collecting visual analogue scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) scores. Global fusion rate and main complications were collected. Results: PT, SS, LL, LLseg and SVA spinopelvic parameters all improved postoperatively by − 4.3 ± 5.2°, 3.9 ± 4.5°, 10.6 ± 12.5°, 6.7 ± 3.5° and 51.1 ± 44.8 mm, respectively. HLC were statistically more effective in restoring LL and LLseg (p < 0.05). Postoperative disc height, anterior disc height, posterior disc height and foraminal height, respectively, increased by 58.5%, 87.2%, 80.9% and 18.1%. Postoperative improvements were observed in VAS back and leg and ODI scores (p < 0.05). The global fusion rate was 94.5 ± 5.5%; the overall complication rate was 13%. Conclusion: When managing sagittal imbalance, ALIF can be considered as a valid technique to achieve the correct spinopelvic parameters based on preoperative planning. This technique permits to obtain an optimal LL distribution and a solid anterior column support, with lower complications and higher fusion rates when compared to posterior osteotomies. [ABSTRACT FROM AUTHOR]

Purpose: This in vitro biomechanical study compares residual lumbar range of motion (ROM) and rod strain after lumbopelvic instrumentation using 2 rods, 4 rods and interbody cages. Methods: Seven human cadaveric specimens were instrumented from L1 to sacrum, and pelvic screws were implanted. The pelvis was constrained and moments up to 7.5 Nm were applied to T12. Segmental L1–S1 ROM was analyzed by tracking radiopaque balls implanted in each vertebra using biplanar radiographs. Deformation within principal rods was measured by strain gauges. Four configurations were compared: 2 rods (2R), 4 rods (4R), 4 rods + ALIF at L4–L5 and L5–S1 (4R + ALIF), 2 rods + ALIF (2R + ALIF). Results: Intact average global L1–S1 ROM was 42.9° (27.9°–66.0°) in flexion–extension (FE), 35.2° (26.8°–51.8°) in lateral bending (LB), 18.6° (6.7°–47.8°) in axial rotation (AR). In FE, average ROM was 1.9° with both 4-rod configurations versus 2.5° with 2R and 2.8° with 2R + ALIF (p < 0.05). In LB, ROM ranged between 1.2° and 1.5° without significant differences. In AR, ROM was 2.5° with both 4-rod configurations versus 2.9° with 2R (p = 0.07) and 3.1° with 2R ALIF (p = 0.01). In FE, strain decreased by 64% and 65% in principal rods at L3–L4 with 4-rod. When comparing 2-rod configurations, strain decreased by 1% in flexion and increased by 22% in extension at L3–L4 when adding an ALIF at L4–L5 and L5–S1. Conclusions: Double rods and interbody cages decrease residual ROM in FE and AT. Double rods seem efficient in limiting strain in principal rods. The use of single rods with cages at the lumbosacral junction increases strain at the first adjacent level without cage. [ABSTRACT FROM AUTHOR]

Purpose: Lumbar spine fusion with anterior (ALIF) or lateral (LLIF) approach is a moderately painful procedure associated with significant length of hospital stay (LoS) and opioid requirements. We developed an opioid-sparing analgesic pathway of care for ALIF and LLIF, featuring transversus abdominis plane (TAP) block. In this study, we assessed the feasibility of performing the TAP block as an analgesic adjunct for ALIF or LLIF.Methods: This is a prospective feasibility study of 32 patients. All patients received pre-incisional TAP block, regularly scheduled non-opioid analgesics (gabapentin, acetaminophen, ketorolac), and oral tramadol, as needed. The primary feasibility outcomes were rates of recruitment, adherence and adverse events associated with the TAP block. Secondary outcomes included assessment of TAP block efficacy and duration, numeric rating scale (NRS) pain scores, LoS and opioid consumption.Results: Thirty-three patients were approached for the study, and all were enrolled. One patient did not have surgery. All patients received the intervention. There were no block-related adverse events. PACU NRS scores were significantly lower (1.9 ± 3.0) than at postoperative day 1 (POD1; 3.3 ± 2.5). The TAP block was effective in 31/32 patients, with 1 failed block. Median LoS was 26.8 h (IQR 22.8-49.5 h). Median opioid consumption was 57.5 oral morphine equivalents (IQR 30-74.38). One patient required opioid iv patient-controlled analgesia.Conclusions: Applying TAP block to spine surgery is a novel pain management strategy. This study demonstrates high patient acceptance and the general safety of the technique. Although lacking a control arm, these results also provide preliminary data supporting efficacy. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Background: Novel oral anticoagulants (NOACs) are being increasingly used in the secondary prevention of thromboembolic stroke in patients with atrial fibrillation. Patients taking NOACs are difficult to manage perioperatively, and several unexpected complications have been reported in these patients.Case Report: We report a case of a rivaroxaban-induced retroperitoneal haematoma in a 72-year-old man who underwent an L5/S1 anterior lumbar interbody fusion (ALIF) for grade 1 spondylolytic spondylolisthesis. The patient suffered from atrial fibrillation and was taking rivaroxaban, a factor Xa inhibitor, for thromboembolic risk reduction. In accordance with perioperative Novel Oral Anticoagulant (NOAC) guidelines, rivaroxaban was stopped 2 days preoperatively and restarted on the third postoperative day. The patient presented on the ninth postoperative day, complaining of severe left iliac fossa pain, nausea, and vomiting, accompanied by swelling and bruising around the surgical site. A computed tomography (CT) scan showed a large expanding retroperitoneal haematoma. The patient was taken back to theatre for an evacuation of the haematoma and subsequently recovered without any further complications.Conclusion: This is the first case of a rivaroxaban-induced retroperitoneal haematoma reported in the literature, secondary to elective spinal surgery. This report adds to the body of evidence on the risk of postoperative bleeding in patients taking NOACs. If patients on NOACs present with abdominal symptoms following anterior approach to the lumbar spine, treating clinicians should have a high index of suspicion for retroperitoneal haematoma. [ABSTRACT FROM AUTHOR]

Purpose: Pedicle subtraction osteotomy (PSO) is performed to treat rigid, sagittal spinal deformities, but high rates of implant failure are reported. Anterior lumbar interbody fusion has been proposed to reduce this risk, but biomechanical investigation is lacking. The goal of this study was to quantify the (1) destabilizing effects of a lumbar osteotomy and (2) contribution of anterior lumbar interbody fusion (ALIF) at the lumbosacral junction as recommended in literature.Methods: Fourteen fresh human thoracolumbosacral spines (T12-S1) were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Bilateral pedicle screws/rods (BPS) were inserted at T12-S1, cross connectors (CC) at T12-L1 and L5-S1, and anterior interbody spacers (S) at L4-5 and L5-S1. In one group, PSO was performed in seven specimens at L3. All specimens were sequentially tested in (1) Intact; (2) BPS; (3) BPS + CC; (4) BPS + S; and (5) BPS + S + CC; a second group of seven spines were tested in the same sequence without PSO. Mixed-model ANOVA with repeated measures was performed (p ≤ 0.05).Results: At the osteotomy site (L2-L4), in FE, BPS, BPS + CC, BPS + S, BPS + CC + S reduced motion to 11.2, 12.9, 10.9, and 11.4%, respectively, with significance only found in BPS and BPS + S construction (p ≤ 0.05). All constructs significantly reduced motion across L2-L4 in the absence of PSO, across all loading modes (p ≤ 0.05). PSO significantly destabilized L2-L4 axial rotational stability, regardless of operative construction (p ≤ 0.05). Across L4-S1 and L2-S1, all instrumented constructs significantly reduced motion, in both PSO- and non-PSO groups, during all loading modes (p ≤ 0.05).Conclusions: These findings suggest anterior interbody fusion minimally immobilizes motion segments, and interbody devices may primarily act to maintain disc height. Additionally, lumbar osteotomy destabilizes axial rotational stability at the osteotomy site, potentially further increasing mechanical demand on posterior instrumentation. Clinical studies are needed to assess the impact of this treatment strategy. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic spondylolisthesis is a challenging condition for spinal surgeons. Posterior surgery in these cases is complicated by poor anatomical landmarks, scar tissue adhesion of muscle and dural structures and difficult access to the intervertebral disc. Anterior interbody fusion provides an alternative treatment method, allowing indirect foraminal decompression, reliable disc clearance and implantation of large surface area implants. Materials and methods: A retrospective chart review of patients with iatrogenic spondylolisthesis including pre- and post-operative Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores was performed. Imaging criteria were pelvic incidence, overall lumbar lordosis and segmental lordosis. In addition, the fusion rate was investigated after 6 months. Results: Six consecutive patients treated between 2008 and 2011 (4 female, 2 male, mean age 61 ± 7.1 years) were identified. The initially performed surgeries included decompression with or without discectomy; posterior instrumented and non-instrumented fusion. The olisthetic level was in all cases at the decompressed level. All patients were revised with stand-alone anterior interbody fusion devices at the olisthetic level filled with BMP 2. Average ODI dropped from 49 ± 11 % pre-operatively to 26.0 ± 4.0 at 24 months follow-up. VAS average dropped from 7 ± 1 to 2 ± 0. Mean total lordosis of 39.8 ± 2.8° increased to 48.5 ± 4.9° at pelvic incidences of 48.8 ± 6.8° pre-operatively. Mean segmental lordosis at L4/5 improved from 10.5 ± 6.7° to 19.0 ± 4.9° at 24 months. Mean segmental lordosis in L5/S1 increased from 15.1 ± 7.4° to 23.2 ± 5.6°. Cage subsidence due to severe osteoporosis occurred in one case after 5 months, and hence there was no further follow-up. Fusion was confirmed in all other patients. Conclusion: Anterior interbody fusion offers good stabilisation and restoration of lordosis in iatrogenic spondylolisthesis and avoids the well-known problems associated with reentering the spinal canal for revision fusions. In this group, ODI and VAS scores were improved. [ABSTRACT FROM AUTHOR]

Purpose: To describe the clinical outcomes and complications in a consecutive series of extreme lateral interbody fusion cases. Methods: Retrospective cohort review of 97 consecutive patients from three centers with minimum 6-month follow-up (mean 12 months). Functional status was evaluated by preoperative and last follow-up Oswestry Disability Index score. Leg and back pain were evaluated by visual analog scales. Complications were recorded and permanent complications and neurological impairment was actively investigated at last follow-up. Results: No permanent neurological impairment, vascular or visceral injuries were observed. Transient neurological symptoms presented in 7% of cases, all resolved within 1 month from surgery. Transient thigh discomfort was observed in 9%. Clinical success was recorded in 92% of cases. Conclusions: Extreme lateral interbody fusion is a safe and effective technique for anterior interbody fusion. [ABSTRACT FROM AUTHOR]

Prospective study. To study the validity of Hybrid construction (Anterior Lumbar Interbody Fusion) ALIF at one level and total disc arthroplasty (TDA) at adjacent, for two levels disc disease in lumbar spine as surgical strategy. With growing evidence that fusion constructs in the treatment of degenerative disc disease (DDD) may alter sagittal balance and contribute to undesirable complications in the long-term, total disc arthroplasty (TDA) slowly becomes an accepted treatment option for a selected group of patients. Despite encouraging early and intermediate term results of single-level total disc arthroplasty reported in the literature, there is growing evidence that two-level arthroplasty does not fare as well. Hybrid fusion is an attempt to address two-level DDD by combining the advantages of a single-level ALIF with those of a single-level arthroplasty. 42 patients (25 females and 17 males) underwent Hybrid fusion and had a median follow-up of 26.3 months. The primary functional outcomes were assessed before and after surgery with Oswestry Disability Index and the visual analogue score of the back and legs. Patients were divided into four groups according to the percentage improvement between preop and postop ODI scores. A total of 42 patients underwent a hybrid fusion as follows: 35 L5-S1 ALIF/L4-5 prosthesis, 3 L4-5 ALIF/L3-4 prosthesis, 2 L5-S1 ALIF/L4-5 prosthesis/L3-4 prosthesis, 1 L5-S1 prosthesis/L4-5 ALIF, and 1 L5-S1 ALIF/L4-5 ALIF/L3-4 prosthesis. At 2-years clinical outcomes, mean reduction in ODI is 24.9 points (53.0% improvement compared to preop ODI). The visual analogue score for the back is 64.6% improvement. At 2-year clinical outcomes, Hybrid fusion is a viable surgical alternative for the treatment of two-level DDD in comparison with two-level TDA and with two-level fusion. [ABSTRACT FROM AUTHOR]

Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified “mini-open anterior spine surgery” (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24–52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12–L1, 18 at L1–L2, 18 at L2–L3, 22 at L3–L4 and 11 at L4–L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62–124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4–26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases. [ABSTRACT FROM AUTHOR]

This biomechanical study was performed to test the primary segmental in vitro stabilising effect of a standard and large footprint radiolucent poly-ether-ether-ketone (PEEK) box cage versus a titanium box cage for anterior lumbar interbody fusion. Eighteen L2-L3 and sixteen L4-L5 cadaveric motion segments were divided into three groups and received a titanium cage or a radiolucent PEEK cage with standard or large footprint. All specimens were tested in three testing conditions: intact, stand-alone anterior cage and finally with supplemental translaminar screw fixation. Full range of motion and neutral zone measurements were determined and anterior cage pull out force was tested. The titanium design was significantly more effective in reducing the range of motion only in axial rotation. The larger footprint radiolucent cage did not increase stability as compared to the standard footprint. The titanium cage pull out force was significantly ( P=0.0002) higher compared to both radiolucent cage constructs. Clinical relevance: Supplemental posterior fixation is strongly recommended to increase initial stability of any anterior interbody fusion cage construct. Although the biomechanical stability necessary to achieve spinal fusion is not defined, the radiolucent designs tested in this study, with a standard footprint as well as with a larger footprint, may be insufficiently stabilised with translaminar screws as compared to the titanium implant. Supplemental pedicle screw fixation may be required to obtain adequate stabilisation in the clinical setting. [ABSTRACT FROM AUTHOR]

The terms ‘minimally invasive’ or ‘less invasive surgery’ have been used recently to describe surgical approaches or operations that are performed with less trauma to anatomical structures on the way to or surrounding the surgical ‘target area’. These types of surgical procedures are usually performed with the help of ‘high-tech’ instruments such as surgical endoscopes or surgical microscopes, modern video techniques and automated instruments. Within the last 10 years, such techniques have been developed in the field of spinal surgery. The application of minimally or less invasive procedures has concentrated predominantly on anterior approaches to the thoracic and lumbar spine. This article describes two anterior approach techniques for performing anterior lumbar interbody fusion (ALIF) through a minimally invasive retroperitoneal or transperitoneal approach. The technical principles are microsurgical modifications of traditional anterior approaches to the lumbar spine. Through small (4-cm) skin incisions, the target area can be exposed. Preliminary results suggest decreased peri - and postoperative morbidity, less blood loss, earlier rehabilitation and acceptable complication rates. The technique is currently used by the author for all patients requiring anterior lumbar interbody fusion. [ABSTRACT FROM AUTHOR]

A retrospective study of 23 patients is presented, all of whom complained of recurrent symptoms of back and leg pain following simple discectomy. Five patients (22%) had been refused further surgery by the original surgeon on the grounds that they were psychologically disturbed. On examining the clinical records, 18 patients were reported to have had frank disc prolapses found at operation. In 5 cases, disc tissues were removed even though disc prolapses had not been demonstrated. Among the 18 patients in whom disc prolapses had been removed at their first operations, we found recurrent prolapses at reoperation in only 2 of them (11%). We treated 19 of these patients by nerve root canal and foraminal decompressions and 4 by anterior lumbar interbody fusion operations. The mean follow-up period was 34 months. Satisfactory relief of symptoms was achieved in 21 cases. In the published literature, even after the advent of CT and MRI, the incidence of recurrent disc prolapse at reoperation varies markedly from author to author. The reasons for these differences are discussed. They appear to relate to three factors: 1. failure to differentiate acute disc prolapse from annular bulging which develops and is inevitably associated with disc space narrowing; 2. difficulty in distinguishing between MRI findings of scar tissue enhancement and local perineural oedema due to persisting foraminal and nerve root canal stenosis; 3. failure to identify the existence of foraminal stenosis, which is sometimes demonstrated only in oblique plain X-rays showing facet hypertrophy and subluxations of zygapophyseal joints.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

We report a case of progressive thrombotic occlusion of the left common iliac artery in a 41-year-old woman after anterior interbody fusion, which initially presented only as a sensation of numbness. Diagnosis was delayed until complete arterial occlusion occurred 36 h after surgery. A sensory deficit may be the only early sign of a progressive thrombotic arterial occlusion. In anterior spinal surgery, routine postoperative vascular monitoring of the lower extremities is recommended and mandatory for early diagnosis and treatment of this rare complication. [ABSTRACT FROM AUTHOR]