Christoph Mehren

Heterotopic ossification in total cervical artificial disc replacement.

Study Design. Prospective clinical study enrolled in 2 centers (Munich and Liberec) as part of a prospective European multicenter study with ProDisc C (Synthes Inc., Paoli, PA). Objectives. The first goal of the study was to evaluate the rate of heterotopic ossifications identified with plain radiograph following total cervical disc replacement (TCDR). The second goal was to show whether segmental motion can be preserved, and whether TCDR can provide improvement of the patient’s ability to perform activities of daily living as well as a decrease of pain. Summary of Background Data. Only a few reports about the radiologic outcome after TCDR are published so far. Heterotopic ossification is a well-known phenomenon after total hip arthroplasty. The rate of heterotopic ossification following TCDR is unclear. Methods. The radiographs of 54 patients (in total, 77 implanted prostheses) were analyzed 1 year after TCDR with a ProDisc C prosthesis. We classified the heterotopic ossification in 5 grades according to a recently published classification system for lumbar total disc replacement. For clinical parameters, the visual analog scale and the Neck Disability Index were evaluated preoperatively and 1 year postoperatively. The Student t test and Wilcoxon test were used for statistical analysis. Results. In 26 treated segments (33.8%), no heterotopic ossification was detectable. Grade 1 ossifications were present in 6 levels (7.8%). A total of 30 segments (39.0%) showed grade 2 ossifications. Heterotopic ossifications that led to restrictions of the range of motion were present in 8 cases (10.4%). One year postoperatively, 7 cases (9.1%) had a spontaneous fusion of the treated segment. The clinical parameters improved significantly and were similar to previous reports about TCDR. Conclusions. Only 33.8% of the patients did not show any signs of heterotopic ossification, and the rate of spontaneous fusion after TCDR 1 year after surgery was unexpectedly high. There were 49.4% of the patients with grade 2-3 ossification, which lets us suspect an even higher rate of spontaneous fusion after long-term follow-ups. Motion preservation after TCDR is only guaranteed if spontaneous fusion can be prevented. Thus, mobility of the implanted segments needs to be further studied.

Der minimalinvasive anterolaterale Zugang zu L2–L5

ZusammenfassungOperationszielMinimalinvasiver anterolateraler retroperitonealer Zugang zu den Segmenten L2–L5.IndikationenVentrale interkorporelle Fusion bei „degenerative disk disease“ (DDD), degenerativer Instabilität, Spondylolisthesis vera und degenerativa Grad I–IV nach Meyerding (meist nach vorangegangener dorsaler Reposition), Tumoren, degenerativen Skoliosen, Frakturen, Spondylodiszitis, „failed back“-Syndrom (Pseudarthrosen, Postnukleotomiesyndrom).KontraindikationenAbsolute Kontraindikationen bestehen nicht.Relative Kontraindikationen sind vorangegangene linksseitige retroperitoneale Eingriffe, Z.n. Peritonitis mit starker Vernarbung, extrem lateral verlaufende Vena iliaca communis linksseitig mit Verlegung des lateralen Anulus des Bandscheibenraums L4/5.OperationstechnikÜber einen kleinen Hautschnitt im Bereich der linken Flanke und einen Wechselschnitt durch die Bauchwandmuskulatur retroperitoneales Eingehen auf die laterale ventrale Wirbelsäule. Subtotale Diskektomie des entsprechenden Levels oder partielle Korporektomie. Einbringen eines Transplantats (autologer bzw. homologer Knochenblock oder Cage) zur ventralen Abstützung.WeiterbehandlungFrühmobilisation vor allem nach entsprechender dorsaler Instrumentation bereits am nächsten Tag unter Thromboseprophylaxe mit fraktioniertem Heparin. Langsamer Kostaufbau bis zum ersten Stuhlgang. Tragen einer stabilisierenden Rumpforthese je nach Art des Eingriffs für bis zu 12 Wochen. Keine Einschränkung bezüglich Gehen, Stehen oder Sitzen auch unmittelbar postoperativ.ErgebnisseBei 120 Patienten mit einem Durchschnittsalter von 56,3 Jahren (26–84 Jahre) wurde in Verbindung mit einer dorsalen Instrumentation über einen minimalinvasiven lateralen retroperitonealen Zugang eine ventrale Spondylodese mit einem autologen Span durchgeführt. Bei 16 Patienten wurde eine bisegmentale Versorgung vorgenommen. Die durchschnittliche Operationszeit betrug 102,2 min (50–192 min). Der Blutverlust war mit durchschnittlich 67,3 cm3 sehr gering. Bei der Verlaufskontrolle nach 6 Monaten konnte eine Fusionsrate von 95,6% festgestellt werden. Gefäßverletzungen oder Verletzungen von Darm, Niere und Milz wurden nicht beobachtet.AbstractObjectiveMinimally invasive anterolateral retroperitoneal approach to the lumbar spinal levels L2–L5.IndicationsAnterior interbody fusion for the treatment of degenerative disk disease (DDD), degenerative instability, isthmic and degenerative spondylolisthesis, tumors, degenerative scoliosis, fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-diskectomy).ContraindicationsNo absolute contraindications.Relative contraindications are previous surgeries via a sinistral retroperitoneal approach or a far lateral anatomy of the left iliac common vein covering the lateral annulus of the disk space L4/5.Surgical TechniqueA small skin incision over the left abdominal wall is followed by a blunt muscle-splitting approach to the retroperitoneal space and the anterolateral circumference of the lumbar spine. A diskectomy, corporectomy and/or grafting (iliac crest or cage) may be performed for a solid ventral fusion.Postoperative ManagementEarly mobilization from the 1st postoperative day in all cases of combined ALIF (anterior lumbar interbody fusion)/ posterior instrumentation procedures. Thromboembolic prophylaxis with fractionated heparin. Light meals up until recovery of the first bowel movements. A brace is recommended depending on the type of the intervention for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.ResultsMinimally invasive anterior interbody fusion procedures with iliac crest bone graft were performed in 120 patients (average age 56.3 years, range 26–84 years) in combination with a dorsal instrumentation. 16 patients were treated with a double-level procedure. Duration of surgery ranged between 50 and 192 min (mean 102.2 min). The intraoperative blood loss was 67.3 cm3. At the 6-month follow-up, the fusion rate was 95.6%. No vessel, bowel, kidney or spleen injuries were observed.

Minimalinvasive ventrale Zugänge zum lumbosakralen Übergang

ZusammenfassungOperationszielRetro- oder transperitoneale, minimalinvasive ventrale Darstellung des lumbosakralen Überganges L5/S1 zur intervertebralen monosegmentalen rigiden (Cage, Knochenspan) oder dynamischen (Bandscheibenprothese) Stabilisierung.IndikationenDegenerative Disc Disease (DDD) mit oder ohne Bandscheibenvorfall. DDD mit translatorischer oder frontaler Instabilität. Degenerative oder isthmische Spondylolisthese. Degeneration von Anschlusssegmenten post fusionem. Failed Back Surgery Syndrome (Postdiskektomie, Pseudarthrose). Spinalstenose mit Segmentinstabilität. Spondylitis und Spondylodiszitis.KontraindikationenVorausgegangene Fusionsoperationen über einen transperitonealen Zugang. Adipositas permagna. Relativ: Vorausgegangene abdominelle oder gynäkologische Operationen. Aorta-Bifurkation und/oder Cava-Confluens unmittelbar vor L5/S1. Große prävertebrale Granulationsgewebsbildung oder Psoasabszess nach Infekten. Erkrankungen des Gastrointestinaltraktes.OperationstechnikVentraler horizontaler oder vertikaler Mittellinienzugang über L5/S1 retroperitoneal oder transperitoneal über rechten oder linken Unterbauch. Retroperitoneale Technik: Medialisieren des Peritonealsackes nach kontralateral. Transperitoneale Technik: Mini-Laparotomie mit Durchqueren von Peritoneum viscerale und parietale und Lateralisieren der Darmkonvolute; dann jeweils Darstellen der anterolateralen Bandscheibenzirkumferenz L5/S1 und Lateralisieren der Gefäße. Diskektomie und Vorbereiten des Implantatlagers.WeiterbehandlungFunktionelle Nachbehandlung und Mobilisation ohne externe Ruhigstellung bei dynamischer Segmentversorgung mit Bandscheibenprothese; dreimonatige Korsettversorgung mit stabilisierender Rumpforthese bei dorsoventraler Spondylodese; keine Einschränkung von Gehen, Stehen oder Sitzen.ErgebnisseVon 01/2002 bis 12/2007 wurden 454 Patienten (248 weiblich, 206 männlich) mit einem Durchschnittalter von 47,3 Jahren (15,4–80,0 Jahre) über einen minimalinvasiven ventralen Zugang im lumbosakralen Übergang wegen unterschiedlicher Indikationen operiert. 251-mal implantierten wir eine Bandscheibenendoprothese, 203-mal fusionierten wir nach dorsaler Instrumentation mit Fixateur interne von ventral mit Cage, trikortikalem Beckenkammspan, Knochenersatzmaterialien wie Hydroxyapatit oder Bone-Morphogenetic-Protein (BMP). Zugangsbedingt kam es bei 0,5% der Patienten zu Gefäßverletzungen – v.a. der Vena iliaca communis links –, Verletzungen des Gastrointestinaltraktes sowie Urogenitaltraktes (Niere, Ureter, Blase) fanden sich nicht, ebenso unter Berücksichtigung der routinemäßigen Nachkontrollen (3, 6, 12 Monate postoperativ) keine Infektionen.AbstractObjectiveMinimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization.IndicationsDegenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis.ContraindicationsPrevious transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract.Surgical TechniqueAnterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed.Postoperative ManagementFunctional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting.ResultsBetween January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.OBJECTIVE Minimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization. INDICATIONS Degenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis. CONTRAINDICATIONS Previous transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract. SURGICAL TECHNIQUE Anterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed. POSTOPERATIVE MANAGEMENT Functional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting. RESULTS Between January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.

[Minimal invasive anterior midline approach to L2-L5].

OBJECTIVE To describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2-L5. INDICATIONS Degenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy) CONTRAINDICATIONS Relative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna. SURGICAL TECHNIQUE Anterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed. POSTOPERATIVE MANAGEMENT Early mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period. RESULTS A minimally invasive midline approach was performed in 686 patients (19-84 years; 94-320 pounds). In 444 cases the levels L2-L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall.ZusammenfassungOperationszielMinimalinvasive ventrale Mittelliniendarstellung der Segmente L2–L5 über einen retroperitonealen oder transperitonealen Zugang.IndikationenDegenerative Bandscheibenerkrankung mit oder ohne Bandscheibenvorfall, welche die Indikation zur Implantation einer Bandscheibenprothese nach sich zieht. Prinzipiell auch degenerative Instabilitäten, Tumoren, Spondylolisthesis vera und degenerativa Grad I–IV nach Meyerding (ggf. nach vorangegangener dorsaler Reposition), Frakturen, Spondylodiscitis, Failed-Back-Syndrom (Pseudarthrosen, Postnukleotomie-Syndrom).KontraindikationenRelative Kontraindikationen sind: Zustand nach abdominellen Eingriffen retro- sowie transperitoneal; Aorta-Bifurkation/ Cava-Confluens unmittelbar vor L4/5; Infektsituation mit großer prävertebraler Granulationsgewebsbildung oder Psoas-Abszess; Adipositas permagna.OperationstechnikAlternativ kann der ventrale Mittellinienzugang transperitoneal oder retroperitoneal über den linken oder auch rechten Unterbauch verwendet werden. Beim transperitonealen Zugang wird das Peritoneum eröffnet und nach Lateralisieren der Eingeweide das entsprechende Segment dargestellt. Beim retroperitonealen Zugang erfolgt das Medialisieren des Peritonealsackes nach kontralateral. Darstellen der entsprechenden anterolateralen Bandscheibenzirkumferenz und Mobilisation der Gefäße je nach Gefäßstatus; Diskektomie und Vorbereiten des Implantatlagers.WeiterbehandlungDie Frühmobilisation erfolgt bereits am nächsten Tag unter Thromboseprophylaxe mit fraktioniertem Heparin. Langsamer Kostaufbau bis zum ersten Stuhlgang. Orthesenfreie Nachbehandlung bei Bandscheibenprothesenimplantation, ansonsten Tragen einer stabilisierenden Rumpforthese je nach Art des Eingriffes für bis zu 12 Wochen. Keine Einschränkung bezüglich Gehen, Stehen oder Sitzen auch unmittelbar postoperativ.ErgebnisseIn einem Gesamtkollektiv von 686 Patienten (19–84 Jahre, 47–160 kg Körpergewicht) wurde bei 444 Patienten ein Mittellinienzugang zu L2–L5 durchgeführt. Die durchschnittliche Explorationszeit zu einem Bandscheibenfach von L2–L5 betrug 22,7 Minuten. 6 Monate postoperativ wurden zugangsbedingte Komplikationen erfasst. Insgesamt wurde in 3,8% der Fälle eine Komplikation festgestellt [1].AbstractObjectiveTo describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2–L5.IndicationsDegenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy)ContraindicationsRelative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna.Surgical TechniqueAnterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed.Postoperative ManagementEarly mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.ResultsA minimally invasive midline approach was performed in 686 patients (19–84 years; 94–320 pounds). In 444 cases the levels L2–L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall [1].

Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach.

A considerable number of varying approach techniques to the neuroforamen and the extraforaminal space have been published previously [1]. One of the primary goals of spinal surgery is to maintain biomechanical stability of the functional spinal unit by avoiding any extensive facet joint resection, as well as to reduce the postoperativemorbidity by minimizing the access related soft tissue trauma. The far lateral paraspinalmuscle splitting approach as outlined in the present manuscript and as previously described by Wiltse et al. [2] resembles a true minimally invasive approach technique in order to address intraand extraforaminal pathologies with minimal soft tissue trauma.

Minimally invasive anterior approaches to the lumbosacral junction

ZusammenfassungOperationszielRetro- oder transperitoneale, minimalinvasive ventrale Darstellung des lumbosakralen Überganges L5/S1 zur intervertebralen monosegmentalen rigiden (Cage, Knochenspan) oder dynamischen (Bandscheibenprothese) Stabilisierung.IndikationenDegenerative Disc Disease (DDD) mit oder ohne Bandscheibenvorfall. DDD mit translatorischer oder frontaler Instabilität. Degenerative oder isthmische Spondylolisthese. Degeneration von Anschlusssegmenten post fusionem. Failed Back Surgery Syndrome (Postdiskektomie, Pseudarthrose). Spinalstenose mit Segmentinstabilität. Spondylitis und Spondylodiszitis.KontraindikationenVorausgegangene Fusionsoperationen über einen transperitonealen Zugang. Adipositas permagna. Relativ: Vorausgegangene abdominelle oder gynäkologische Operationen. Aorta-Bifurkation und/oder Cava-Confluens unmittelbar vor L5/S1. Große prävertebrale Granulationsgewebsbildung oder Psoasabszess nach Infekten. Erkrankungen des Gastrointestinaltraktes.OperationstechnikVentraler horizontaler oder vertikaler Mittellinienzugang über L5/S1 retroperitoneal oder transperitoneal über rechten oder linken Unterbauch. Retroperitoneale Technik: Medialisieren des Peritonealsackes nach kontralateral. Transperitoneale Technik: Mini-Laparotomie mit Durchqueren von Peritoneum viscerale und parietale und Lateralisieren der Darmkonvolute; dann jeweils Darstellen der anterolateralen Bandscheibenzirkumferenz L5/S1 und Lateralisieren der Gefäße. Diskektomie und Vorbereiten des Implantatlagers.WeiterbehandlungFunktionelle Nachbehandlung und Mobilisation ohne externe Ruhigstellung bei dynamischer Segmentversorgung mit Bandscheibenprothese; dreimonatige Korsettversorgung mit stabilisierender Rumpforthese bei dorsoventraler Spondylodese; keine Einschränkung von Gehen, Stehen oder Sitzen.ErgebnisseVon 01/2002 bis 12/2007 wurden 454 Patienten (248 weiblich, 206 männlich) mit einem Durchschnittalter von 47,3 Jahren (15,4–80,0 Jahre) über einen minimalinvasiven ventralen Zugang im lumbosakralen Übergang wegen unterschiedlicher Indikationen operiert. 251-mal implantierten wir eine Bandscheibenendoprothese, 203-mal fusionierten wir nach dorsaler Instrumentation mit Fixateur interne von ventral mit Cage, trikortikalem Beckenkammspan, Knochenersatzmaterialien wie Hydroxyapatit oder Bone-Morphogenetic-Protein (BMP). Zugangsbedingt kam es bei 0,5% der Patienten zu Gefäßverletzungen – v.a. der Vena iliaca communis links –, Verletzungen des Gastrointestinaltraktes sowie Urogenitaltraktes (Niere, Ureter, Blase) fanden sich nicht, ebenso unter Berücksichtigung der routinemäßigen Nachkontrollen (3, 6, 12 Monate postoperativ) keine Infektionen.AbstractObjectiveMinimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization.IndicationsDegenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis.ContraindicationsPrevious transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract.Surgical TechniqueAnterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed.Postoperative ManagementFunctional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting.ResultsBetween January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.OBJECTIVE Minimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization. INDICATIONS Degenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis. CONTRAINDICATIONS Previous transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract. SURGICAL TECHNIQUE Anterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed. POSTOPERATIVE MANAGEMENT Functional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting. RESULTS Between January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.

[The minimally invasive anterolateral approach to L2-L5].

ZusammenfassungOperationszielMinimalinvasiver anterolateraler retroperitonealer Zugang zu den Segmenten L2–L5.IndikationenVentrale interkorporelle Fusion bei „degenerative disk disease“ (DDD), degenerativer Instabilität, Spondylolisthesis vera und degenerativa Grad I–IV nach Meyerding (meist nach vorangegangener dorsaler Reposition), Tumoren, degenerativen Skoliosen, Frakturen, Spondylodiszitis, „failed back“-Syndrom (Pseudarthrosen, Postnukleotomiesyndrom).KontraindikationenAbsolute Kontraindikationen bestehen nicht.Relative Kontraindikationen sind vorangegangene linksseitige retroperitoneale Eingriffe, Z.n. Peritonitis mit starker Vernarbung, extrem lateral verlaufende Vena iliaca communis linksseitig mit Verlegung des lateralen Anulus des Bandscheibenraums L4/5.OperationstechnikÜber einen kleinen Hautschnitt im Bereich der linken Flanke und einen Wechselschnitt durch die Bauchwandmuskulatur retroperitoneales Eingehen auf die laterale ventrale Wirbelsäule. Subtotale Diskektomie des entsprechenden Levels oder partielle Korporektomie. Einbringen eines Transplantats (autologer bzw. homologer Knochenblock oder Cage) zur ventralen Abstützung.WeiterbehandlungFrühmobilisation vor allem nach entsprechender dorsaler Instrumentation bereits am nächsten Tag unter Thromboseprophylaxe mit fraktioniertem Heparin. Langsamer Kostaufbau bis zum ersten Stuhlgang. Tragen einer stabilisierenden Rumpforthese je nach Art des Eingriffs für bis zu 12 Wochen. Keine Einschränkung bezüglich Gehen, Stehen oder Sitzen auch unmittelbar postoperativ.ErgebnisseBei 120 Patienten mit einem Durchschnittsalter von 56,3 Jahren (26–84 Jahre) wurde in Verbindung mit einer dorsalen Instrumentation über einen minimalinvasiven lateralen retroperitonealen Zugang eine ventrale Spondylodese mit einem autologen Span durchgeführt. Bei 16 Patienten wurde eine bisegmentale Versorgung vorgenommen. Die durchschnittliche Operationszeit betrug 102,2 min (50–192 min). Der Blutverlust war mit durchschnittlich 67,3 cm3 sehr gering. Bei der Verlaufskontrolle nach 6 Monaten konnte eine Fusionsrate von 95,6% festgestellt werden. Gefäßverletzungen oder Verletzungen von Darm, Niere und Milz wurden nicht beobachtet.AbstractObjectiveMinimally invasive anterolateral retroperitoneal approach to the lumbar spinal levels L2–L5.IndicationsAnterior interbody fusion for the treatment of degenerative disk disease (DDD), degenerative instability, isthmic and degenerative spondylolisthesis, tumors, degenerative scoliosis, fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-diskectomy).ContraindicationsNo absolute contraindications.Relative contraindications are previous surgeries via a sinistral retroperitoneal approach or a far lateral anatomy of the left iliac common vein covering the lateral annulus of the disk space L4/5.Surgical TechniqueA small skin incision over the left abdominal wall is followed by a blunt muscle-splitting approach to the retroperitoneal space and the anterolateral circumference of the lumbar spine. A diskectomy, corporectomy and/or grafting (iliac crest or cage) may be performed for a solid ventral fusion.Postoperative ManagementEarly mobilization from the 1st postoperative day in all cases of combined ALIF (anterior lumbar interbody fusion)/ posterior instrumentation procedures. Thromboembolic prophylaxis with fractionated heparin. Light meals up until recovery of the first bowel movements. A brace is recommended depending on the type of the intervention for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.ResultsMinimally invasive anterior interbody fusion procedures with iliac crest bone graft were performed in 120 patients (average age 56.3 years, range 26–84 years) in combination with a dorsal instrumentation. 16 patients were treated with a double-level procedure. Duration of surgery ranged between 50 and 192 min (mean 102.2 min). The intraoperative blood loss was 67.3 cm3. At the 6-month follow-up, the fusion rate was 95.6%. No vessel, bowel, kidney or spleen injuries were observed.

Minimalinvasive ventrale Mittellinienzugänge L2–L5

OBJECTIVE To describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2-L5. INDICATIONS Degenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy) CONTRAINDICATIONS Relative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna. SURGICAL TECHNIQUE Anterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed. POSTOPERATIVE MANAGEMENT Early mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period. RESULTS A minimally invasive midline approach was performed in 686 patients (19-84 years; 94-320 pounds). In 444 cases the levels L2-L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall.ZusammenfassungOperationszielMinimalinvasive ventrale Mittelliniendarstellung der Segmente L2–L5 über einen retroperitonealen oder transperitonealen Zugang.IndikationenDegenerative Bandscheibenerkrankung mit oder ohne Bandscheibenvorfall, welche die Indikation zur Implantation einer Bandscheibenprothese nach sich zieht. Prinzipiell auch degenerative Instabilitäten, Tumoren, Spondylolisthesis vera und degenerativa Grad I–IV nach Meyerding (ggf. nach vorangegangener dorsaler Reposition), Frakturen, Spondylodiscitis, Failed-Back-Syndrom (Pseudarthrosen, Postnukleotomie-Syndrom).KontraindikationenRelative Kontraindikationen sind: Zustand nach abdominellen Eingriffen retro- sowie transperitoneal; Aorta-Bifurkation/ Cava-Confluens unmittelbar vor L4/5; Infektsituation mit großer prävertebraler Granulationsgewebsbildung oder Psoas-Abszess; Adipositas permagna.OperationstechnikAlternativ kann der ventrale Mittellinienzugang transperitoneal oder retroperitoneal über den linken oder auch rechten Unterbauch verwendet werden. Beim transperitonealen Zugang wird das Peritoneum eröffnet und nach Lateralisieren der Eingeweide das entsprechende Segment dargestellt. Beim retroperitonealen Zugang erfolgt das Medialisieren des Peritonealsackes nach kontralateral. Darstellen der entsprechenden anterolateralen Bandscheibenzirkumferenz und Mobilisation der Gefäße je nach Gefäßstatus; Diskektomie und Vorbereiten des Implantatlagers.WeiterbehandlungDie Frühmobilisation erfolgt bereits am nächsten Tag unter Thromboseprophylaxe mit fraktioniertem Heparin. Langsamer Kostaufbau bis zum ersten Stuhlgang. Orthesenfreie Nachbehandlung bei Bandscheibenprothesenimplantation, ansonsten Tragen einer stabilisierenden Rumpforthese je nach Art des Eingriffes für bis zu 12 Wochen. Keine Einschränkung bezüglich Gehen, Stehen oder Sitzen auch unmittelbar postoperativ.ErgebnisseIn einem Gesamtkollektiv von 686 Patienten (19–84 Jahre, 47–160 kg Körpergewicht) wurde bei 444 Patienten ein Mittellinienzugang zu L2–L5 durchgeführt. Die durchschnittliche Explorationszeit zu einem Bandscheibenfach von L2–L5 betrug 22,7 Minuten. 6 Monate postoperativ wurden zugangsbedingte Komplikationen erfasst. Insgesamt wurde in 3,8% der Fälle eine Komplikation festgestellt [1].AbstractObjectiveTo describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2–L5.IndicationsDegenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy)ContraindicationsRelative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna.Surgical TechniqueAnterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed.Postoperative ManagementEarly mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.ResultsA minimally invasive midline approach was performed in 686 patients (19–84 years; 94–320 pounds). In 444 cases the levels L2–L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall [1].

Minimally invasive anterior oblique lumbar interbody fusion (OLIF)

The anterior interbody fusion of the lumbar spine is a fixed constituent in spine surgery. The now called OLIF approach to the lumbar spine is using an anatomical pathway through the retroperitoneal space in between the psoas muscle and the big abdominal vessels. With this kind of minimally anterior psoas-respecting approach, invented by Mayer already [1], an intraoperative neuromonitoring is not needed. Case description

Minimally invasive posterior segmental instrumentation and fusion with an intraarticular facet joint device.

Minimally posterior instrumentation and fusion techniques became very attractive in the last years. The approach of facet joint blocking with a screw was first described by King in 1944 [1]. Over time some technical modification of ‘‘facet joint instrumentation’’ were made. Magerl developed the translaminar facet screw with good long-term outcomes for patients with a strict indication for short segment spondylodesis, intact posterior elements and a low preoperative disc height [2, 3]. Anothermodificationwas the facet interference screw, which shows similar biomechanical primary stability characteristics like the translaminar screw. All these different techniques had in common, that the primary stability was inferior to the ‘‘gold standard’’ pedicle screws, especially in extension and rotation [4]. In 2014 Hartensuer et al. [5] published a biomechanical evaluation of a refined technique for lumbar facet fixation—so called Facet Wedge—and demonstrated that this device has a comparable primary stability to pedicle screws. Nevertheless, up to now there is a lack of clinical studies regarding this facet fixation technique, but the own preliminary clinical experience with this minimally invasive additional posterior intraarticular instrumentation and fusion are very promising.